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PUBLISHED JULY 1, 1943 


by 

UNITED SEAMEN’S SERVICE, INC. 


Prepared for Publication by 

THE DEPARTMENT OF PUBLIC RELATIONS, 
UNITED SEAMEN’S SERVICE, INC. 


39 Broadway 


New York City 


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PROCEEDINGS 


Conference on 

TRAUMATIC WAR NEUROSES 
IN MERCHANT SEAMEN 

THE MEDICAL PROGRAM 

of the 

WAR SHIPPING ADMINISTRATION (RMO) 

and 

UNITED SEAMEN’S SERVICE, INC. 

Under the Guidance of 

UNITED STATES PUBLIC HEALTH SERVICE 


IHE IIBRA.S^V OP 

CONGRESS 
SERIAL RtCORU 

FEB1B’-944 

Copy-- 

GOVT. SOURCE 


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January 28, 1943 • 

New York Academy of Medicine 
2 East 103rd Street 


New York City 





From the Medical Department of the 
War Shipping Administration (RMO) 

and 

United Seamen’s Service, Inc. 

Daniel Blain, Surgeon (R) 

United States Public Health Service, Director. 


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CONFIDENTIAL FOR PHYSICIANS’ USE ONLY IN CONNECTION 
WITH THE WAR EFFORT. NOT FOR NEWSPAPER RELEASE OR 
DISCUSSION WITHOUT PRIOR PERMISSION IN WRITING OF THE 
RECRUITMENT AND MANNING ORGANIZATION OF THE WAR 

SHIPPING ADMINISTRATION. 



MEMBERS PRESENT AT THE CONFERENCE 

United States Army Medical Corps 

Brig. General DAVID N. W. GRANT Col. ROY D. HALLORAN 

Major JOHN M. MURRAY 

United States Navy Medical Corps 

Capt. A. A. MARSTELLER Lieut. HOWARD P. ROME 

Royal Navy Medical Corps 
Surg. Comdr. R. W. MUSSEN 


Royal Canadian Air Force 
Flight Surgeon C. G. STOGDILL 

Royal Canadian Navy 
Surg. Lt. MERVIN WELLMAN 

Royal Canadian Medical Corps 
Brigadier G. D. CHISHOLM 


Norwegian Public Health Service 

Surgeon General KARL EVANG Dr. WILLIAM HOFFMAN 

U. S. Veteran*s Administration 
Dr. HUGO MELLA 


U. S. Public Health Service 


Surgeon General THOMAS PARRAN 
Asst. Surgeon Gen. WM. F. OSSENFORT 
Asst. Surgeon Gen. LAWRENCE KOLB 
Medical Director FRANK M. FAGET 
Medical Director JUSTIN K. FULLER 
Medical Director CARL MICHEL 
Sr. Surgeon WALTER G. NELSON 
Sr. Surgeon R. C. WILLIAMS 
Sr. Surgeon WM. Y. HOLLINGSWORTH 


P. A. Surgeon (R) HEWITT 1. VARNEY 

P. A. Surgeon S. D. VESTERMARK 

P. A. Surgeon (R) LESLIE H. FARBER 

P. A. Surgeon R. N. FELIX 

Acting Asst. Surgeon HAROLD KELMAN 

Dr. BEATRICE BERLE 

Dr. S. W. HAMILTON 

Dr. TITUS HARRIS 

Dr. JOHN MUSSER 


Surgeon (R) EVERETT S. RADEMACHER 


(Continued on next page) 


Civilians 


Dr. VIOLA BERNARD 
Dr. EARL D. BOND 
Dr. KARL BOWMAN 


Dr. WILLIAM MALAMUD 
**Dr. ROBERT B. McGRAW 


♦* ** Dr. RICHARD BRICKNER 


Dr. A. A. BRILL 
Dr. DEXTER M. BULLARD 
Dr. C. C. BURLINGAME 
Dr. C. MACFIE CAMPBELL 
Dr. ROSS McC. CHAPMAN 
Dr. CLARENCE O. CHENEY 
Dr. GEORGE E. DANIELS 
Mr. AUSTIN M. DAVIES 
Dr. FELIX DEUTSCH 
Dr. FRANK FREMONT-SMITH 
Dr. BERNARD GLUECK 
Dr. ROSCOE HALL 
Dr. ABRAM KARDINER 
♦Dr. FOSTER KENNEDY 
Dr. CHARLES H. KIMBERLY 
Dr. LAWRENCE S. KUBIE 
Dr. NOLAN D. C. LEWIS 


Dr. KARL MENNINGER 
Dr. ADOLF MEYER 
Dr. JOHN A. P. MILLET 
Dr. WINFRED OVERHOLSER 
Dr. FREDERICK W. PARSONS 
♦Dr. TRACY J. PUTNAM 
Dr.SANDOR RADO 
Mr. ELMER ROESSNER (O.W.I.) 
Dr. ARTHUR RUGGLES 
Dr. LAUREN H. SMITH 
Dr. GEO. S. STEVENSON 
Dr. EDW. A. STRECKER 
Dr. HARRY S. SULLIVAN 
Dr. THEODORE A. WATTERS 
Dr. JOHN C. WHITEHORN 
Dr. DAVID WECHSLER 
Dr. H. B. WILCOX 
Dr. VERNON P. WILLIAMS 
♦Dr. S. BERNARD WORTIS 


WSA (RMO) and USS 


Mr. MARSHALL E. DIMOCK, Assistant Deputy Administrator, 
Recruitment and Manning Organization 

Mr. DOUGLAS P. FALCONER, National Executive Director, 
United Seamen’s Service, Inc. 

Surgeon (R) DANIEL BLAIN, Medical Director 

P. A. Surgeon (R) WILLIAM BELLAMY, Asst. Medical Director 

Miss MADELINE OLDFIELD, Executive Assistant 

P. A. Surgeon STEPHEN SHERMAN, Chief Medical Officer 

Dr. GRACE BAKER, Chief Medical Officer 

Dr. MARGARET DeRONDE, Chief Medical Officer 

Dr. PAUL HENRY HOCH, Chief Medical Officer 

Mr. NELS ANDERSON, Director, Service Division, R.M.O. 

Mr. GEORGE L. WHITE, JR., R.M.O. 

Dr. HOWARD POTTER, Medical Supervisor, New York 


■>' ■ 



* Present in the afternoon 

** Present in the evening 


TABLE OF CONTENTS 


PAGE 

Introduction . 11 

Etiology and Pathology. 37 

Treatment . 57 

Prevention . 91 

Conclusion. 141 










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INVITATION TO CONFERENCE 


The United States Public Health Service has been 
collaborating with the United Seamen's Service and 
the War Shipping Administration in a program for 
the prevention and treatment of psychiatric casualties 
among merchant seamen, with special reference to the 
traumatic war neuroses. The plan has been in opera¬ 
tion for several months and a considerable amount of 
very pertinent experience has been accumulated. 

A definite procedure has been followed and several 
hundred patients have been treated. We have now 
arrived at the stage where it is felt that the general plan 
could be greatly helped by consultation with a few out 
standing physicians, including representatives from 
other government services. With this in mind I am 
extending an invitation to you to attend a conference 
at the Academy of Medicine in New York, on January 
28, 1943, in order to discuss the various problems that 
have arisen and the possibilities for improving the 
program. 

There will be an all day session, beginning at 9:30 
in the morning. Those attending will be the guests of 
the Josiah Macy, Jr. Foundation at luncheon and at 
dinner. Expenses of travel will be paid by the Founda¬ 
tion. 

I shall appreciate your letting me know that you 
will attend. 

Thomas Parran^ 

Surgeon General (U.S.P.H.S.) 




« 


INTRODUCTION 




MEMORANDUM ACCOMPANYING 
INVITATION TO CONFERENCE 

The distress of merchant seamen following bombing and tor¬ 
pedoing experiences led Rear Admiral Emory S. Land to request 
Surgeon General Thomas Parran to furnish the War Shipping 
Administration with doctors to provide help for those men. It was 
apparent that this program should fill the gap where the hospitals 
and clinics of United States Public Health Service left off—that 
convalescent and rest facilities were needed and that the great need 
was for treatment and prevention of the nervous conditions mani¬ 
fested by a very high proportion of survivors. 

The work divided itself into three phases: Meeting survivors and 
providing emergency care for them as they returned to American 
shores; referring to appropriate hospital and clinic facilities those 
with medical and surgical conditions; and operating a series of cen¬ 
ters or hospitals designed to care for those suffering from traumatic, 
war neurosis. 

The program developed is one wherein psychiatry predominates. 
The centers are open to somatic convalescents, but location, size, 
nursing care are all devised with the interests of victims of traumatic 
the general program of food, recreation and exercise, medical and 
war neuroses chiefly in mind. 

The United Seamen’s Service is shouldering an increasing 
amount of the responsibility for operating small units known as con¬ 
valescent and rest centers. Five of them are functioning and if 
operated at a maximum capacity will take care of more than 4000 
cases a year, giving each patient three weeks of care under what we 
consider the most ideal conditions for treatment. 

CHIEF ASPECTS OF TREATMENT AVAILABLE TO ANY 
BONA FIDE MERCHANT SEAMAN 

1. Free care with expenses partly paid by the War Shipping Admin¬ 
istration,® and all resources of United Seamen’s Service for 

personal service. 

♦The United Seamen’s Service assumed a major share in the financing of the medical 
program as of July 1, 1943. By resolution of its executive committee and with the agree¬ 
ment of the War Shipping Administration, this step was undertaken by the United Seamen’s 
Service in conformity with the purposes for which it was founded— ^The Editor. 

11 



1 


i 



12 TRAUMATIC WAR NEUROSES 

# 

2. Rest centers limited to 50 men (preferably 35) in informal sur¬ 
roundings, rural atmosphere, quiet, with plenty of space, nearly 
always on salt water and no hospital atmosphere. 

3. The head nurse is carefully picked for long psychiatric training 
in cases of psychoneurosis and mild anxiety states and both 
administrative and private-duty experience. No uniforms are 
worn. The head nurse is the house mother. 

4. Great emphasis is placed on personal attention and food, with 
frequent feedings, ship’s hours. The chef is an ex-shipsteward. 

5. Medical treatment. 

(a) Supportive: Food, rest, quiet, sedation, vitamins, personal 
attention, recreation, exercise, nursing care, occupational therapy. 

Recreation in hands of local social committee that provides 
hostesses, games, entertainment, invitations, etc. All events must 
be approved by the doctor or nurse. Too much excitement and 
too much entertainment defeats our purpose. 

Evidence of general good-will of neighborhood toward seamen 
and praise for their exploits are used as an emotional tonic. 

(b) Direct psychotherapy: Personal interviews. First inter¬ 
view for history, catharsis and beginning of patient-doctor rela¬ 
tionship—45 to 60 minutes. Thereafter, about three ten-minute 
private interviews a week. 

Group talks and discussions. The doctor talks to the whole 
group two to three times a week on subjects pertaining to mental 
hygiene, anatomy, physiology, psychosomatic relationships, 
fatigue, sleep and rest. Nightmares, fear, anger and like topics 
are dealt with in straightforward simple language, avoiding all 
psychiatric terminology. 

Traumatic war neurosis is called “war nerves;’’ the psychia¬ 
trist is the doctor; all treatment is medical; no psychotics are 
admitted; behavior problems which we cannot control are elim¬ 
inated for the sake of the group; chronic alcholics and chronic 
psychoneurotics are refused admission except for special reasons. 

Length of stay is now limited to three weeks. After the first 
four months, experience has shown that most men leave earlier 
and only those rapidly becoming chronic will tend to remain 
longer. 

Staff psychiatrists are civilians in most instances, men or 
women whose experience has been with mild anxiety states 


INTRODUCTION 


IS 


rather than with psychotics. We have been successful so far in 
persuading well-trained and leading psychiatrists to come in on a 
half-time basis as appointees of the United States Public Health 
Service because of the material available and the atttraction of 
a war job. 

In all of the centers it has proved desirable to encourage a close 
working relationship with a leading school of medicine. This re¬ 
lationship is of advantage to our service as it tends to keep the pro¬ 
fessional work at a good level and to stimulate a research point of 
view; it is of advantage to the medical school because it has an im¬ 
portant educational value. The following medical schools have 
formally sponsored one of our convalescent homes and have aided in 
securing psychiatric consultants from their staffs: 

In order of their acceptance: 

Long Island College of Medicine 
Columbia University ' 

Johns Hopkins University 
Tulane University 
University of California 

The chief topics for discussion at this meeting are: 

1. Etiology and Psychopathology of TraumaticWar Neuroses 

2. Treatment of Traumatic War Neuroses. 

3. Prevention of Traumatic War Neuroses. 

4. General program to meet the needs in the American Mer¬ 

chant Marine. 

Daniel Blain^ Surgeon (R), 
United States Public Health Service 



MORNING SESSION 


INTRODUCTION 

The Conference on Traumatic War Neuroses in Merchant 
Seamen, the Medical Program of the War Shipping Administration, 
Recruitment and Manning Organization, and United Seamen’s 
Service, Inc., under the guidance of the United States Public Health 
Service, convened in the New York Academy of Medicine at 9:55 
a.m. Eastern War Time, Surgeon General Thomas Parran, United 
States Public Health Service, presiding. 

Chairman Parran: The conference will be in order. 

I am very glad to welcome you colleagues here today to discuss 
an important medical war problem. We are glad to have repre¬ 
sentatives from the United States Army and Navy, and especially 
glad to have representatives from the Norwegian Government and 
from the Royal Canadian Army, Navy and Air Force. 

In 1798 the Congress created the parent organization of the 
present Public Health Service to give medical care to merchant sea¬ 
men. During the ensuing 145 years many other duties have been 
added but the care of merchant seamen has remained one of our 
important functions. The medical officers of the Service have had 
an unusual opportunity to study the characteristics and health prob¬ 
lems of this industrial group. These seamen are a hardy group of 
people peculiarly adapted to the life they have chosen. They have 
an important responsibility in times of peace. The ships they man 
carry millions of tons of valuable cargo on long ocean voyages. 

Since the outbreak of the present war, the responsibilities and 
hazards of the Merchant Marine have increased many times. The 
transportation of goods and implements of war to ports of the 
Allied nations and to our fighting forces abroad is of basic impor¬ 
tance to our war effort. That the enemy should seek to cut our 
supply lines by all possible means is to be expected. The men of 
the Merchant Marine are in constant danger of attack on the high 
seas by enemy surface raiders and enemy submarines. How many 
merchant ships have been lost and how many seamen have been 
killed by direct enemy action or have lost their lives as a sequel of 

15 


16 


TRAUMATIC WAR NEUROSES 


this action cannot be stated even in this closed meeting. The totals 
are large. 

The slowly moving merchant vessel faces the possibility of tor¬ 
pedoing a few hours after the voyage begins and continues to face 
it night and day for several weeks or until the voyage is completed. 
The continued apprehension of members of the crew constitutes of 
itself a stress of unusual magnitude. When the ship is attacked, 
the danger becomes real and the stress is greatly intensified. This 
change in most instances takes place without warning and represents 
a sudden, life-threatening situation. Some men are killed immedi¬ 
ately by the force of the explosion. Others suffer severe physical 
injury. Those not suffering trauma at the moment are faced with 
having to man the crippled ship under exceptional circumstances 
for varying lengths of time. The ship may need to be abandoned 
in a few minutes after the attack is begun. In some instances there 
is not even enough time to lower the lifeboats. Fire makes the 
picture even more terrifying. 

Those who survive these major experiennces to the extent of get¬ 
ting aboard a life raft or lifeboat are then called upon to suffer the 
physical effects of exposure to the elements with marked restrictions 
of food, water, and activity. That some should have a feeling of 
utter helplessness is not surprising. The matter of remaining afloat 
for hours, days, and even weeks under these circumstances consti¬ 
tutes a physical and mental strain which is quite likely to produce, 
even in the strongest individuals undergoing them, pathological 
changes in anatomy, physiology, and psychology. That great num- 
bers of men have survived these ordeals is a tribute to their capacity 
to adjust to such unusual hardships; but the ordeal all too often is 
so severe and so prolonged that even experienced seamen with more 
than average stability break under the strain. Naturally, among the 
large number of inexperienced sailors are many who are susceptible 
to severe nervous breaks. Numerous psychiatric casualties have 
occurred. We want to prevent as many of these as possible, both 
in the veteran and in the new recruit, and to treat by the most 
effective means those who do succumb. I hope that the syndrome 
of so-called traumatic war neurosis will be discussed quite freely today 
with a view of arriving at the best possible means of prevention and 
of handling the individual cases with the maximum benefit in the 
shortest time possible. The longer a neurosis continues, the more 
unfavorable becomes the prognosis. 

For a number of months the Public Health Service and the War 



INTRODUCTION 


17 


Shipping Administration have collaborated in a program designed 
to do all that is possible for these cases. 

I should explain that the Public Health Service operates the 
medical service of the War Shipping Administration in a way com¬ 
parable to that in which we give medical care to the Coast Guard. 
The scope and details will be presented by those who are doing the 
work. A considerable number of cases have been treated and the 
results are encouraging. 

We must do our very best for these brave fighters of the supply 
battle, to keep them fit and to heal their wounds of body and mind. 
With this end in view, I welcome you to this conference. My col¬ 
league and I seek your aid in improving our services. Conclusions 
reached here also should have a direct bearing upon comparable 
problems in the other fighting forces. 

Since all of us do not know each other, I am going to suggest 
that we have each of you in turn rise and give your name and your 
representation. 

The first item on the program is a discussion of the program 
being carried out in connection with the Maritime Commission (War 
Shipping Administration), and United Seamen’s Service, by Dr. 
Daniel Blain. 

Dr. Daniel Blain: This group contains seven doctors who met 
with me several times last spring after the American Psychiatric 
Association Meeting in Boston, to discuss cases of merchant seamen 
sent to me by the British Vice Consul. Twice we were entertained at 
dinner by the Josiah Macy, Jr. Foundation, who are our hosts today. 
Some of us had been active in a seminar course of ten sessions on 
war neurosis earlier that year. As a result of these contacts, as well 
as of visiting hospitals in Halifax and the Norwegian Home for Sea¬ 
men in Chester, Nova Scotia, and of a number of discussions with 
leaders of the War Shipping Administration and a large number of 
seamen themselves, I came to the planning of this program with a 
certain clear concept of the definition, treatment and prevention of 
traumatic war neuroses. 

My first case was dramatic in its implications. A 27-year-old 
English boy presented three kinds of symptoms. He was mildly 
depressed; he had attacks of increasing tension when he felt he must 
cry out and yell when in a social group, at which he would leave 
and go to the men’s room, weep for a few minutes and come back 
feeling all right; and attacks similar to nightmares before going to 


18 


TRAUMATIC WAR NEUROSES 


sleep at night. In these attacks he would be ready to go to sleep 
when he would start thinking of various incidents—torpedoing in 
the Channel, a week of bombing in Harley Pool without sleep for 
a solid week, ships sinking around him in convoys, his 2nd mate who 
had gone crazy, planes diving, bombs dropping, home, his wife 
and the child he hadn’t seen, etc.—the events of the last voyage with 
shortage of food, no refrigeration, bad feeling among the ship’s com¬ 
pany. Then memories followed each other faster and faster, racing 
around his head until he thought it would split. He would look 
around and objects appeared far away, his hand ten feet off, the 
house across the street ten blocks away. He would get up, walk 
about, smoke a cigarette and it would all pass off. Then he would 
go to sleep without further trouble. During this time he had palpi¬ 
tation, sweating, trembling waves of hot and cold over his body. 
There is not time for a detailed history, but he had an essentially 
normal past. There were some morbid facts in his life, but he 
had been doing well in business and had married a short time before 
the war opened. 

He was trained for the sea. He joined up and had had two years 
and three months of a tough life—no real vacation, any number of 
bad actions, seen ships and men lost time after time, and didn’t 
crack up through it all. Then a series of events occurred which 
appeared significant. The last trip began with delays—going 
aground in the harbor, removal of stores, more delay. Then long 
tropical experiences with no refrigeration and shortage of food, 
grumblings among crew and officers. Ulcer-like symptoms developed 
with increasing severity for three months, culminating in a collapse 
with terrific abdominal pain on deck the second night in New York. 
He was taken by ambulance to a hospital. There were no x-ray 
findings, no blood and the diagnosis was spasm. Discharged in two 
weeks as physically sound and told to rest up a few weeks for his 
nerves, he was never aware of being nervous or emotionally upset 
until just before leaving the hospital. Then he got despondent and 
unhappy and went to a hotel where his agents paid his room and 
board. 

He soon spent a few dollars he had borrowed and could get no 
cash advance on his pay due in England. His consul could do 
nothing for him. He felt ill but could get no help. Although 
entertained at canteens and given free theatre tickets, he hadn’t a 
nickel for subway rides or cigarettes. He came to me after three 
weeks, after telling the consul if nothing could be done for him, he 


( 


INTRODUCTION 


19 


wanted to go back to sea and bloody well get knocked ofiE. After a 
few minutes of talking, he suddenly came out with a terrific blast 
against his last skipper and for ten minutes poured out a mass of 
hostility that gave me the surprise of my life. Instead of all his 
other troubles, before and since his collapse, this one feeling that 
the skipper had grafted on the stores, was incompetent and had not 
properly kept his vessel fit, suggested itself to me as either the cause 
of his break or the last straw in a series of similar disappointments 
or causes of being let down. Then followed being sent out and told 
he was all right when he knew he was not fit to look after himself— 
government and old legal barriers prevented his having any money. 
A jeweler in New York took his watch for repairs and sold it, saying 
he thought the owner had gone back to sea. The boy was treated 
in my office and lost all symptoms, got back his zest for living and 
sailed away on a ship not bound for home. I had one letter shortly 
afterward. 

His case showed several things. An emotionally healthy fellow 
had cracked up. He had gone through two years and three months 
of danger, strain, fatigue and all manner of experience before this 
occurred. A period of bad feelings with his skipper predominated 
over other feelings. He didn’t crack until he was in harbor and was 
not aware of being nervous until he was told he was physically well 
and had been lying quietly in a hospital for a week. His symptoms 
increased as his environment added not to danger but to frustration. 
He was a relatively easy cure, but not with kindness alone. He had 
to have intellectual understanding of his symptoms and his feelings. 

In order to show you one or two of the men we have actually 
been receiving, we have arranged for one or two patients to appear 
here. Dr. Hoch, will you bring the gentleman in? 

Some of our men don’t object to seeing doctors; in fact, they are 
rather flattered. 

This is Mr. Lambert. Dr. Hoch, will you tell a little bit about 
Mr. Lambert? 

Dr. Hoch: Will you tell us what happened to you, Mr. 
Lambert? 

Mr. Lambert: Yes, sir. We had been under attack for two 
days in Northern Russia and on the 14th of September in the after¬ 
noon, they gave us a heavy attack. They attacked us with about 
thirty planes. They machine-gunned us and used heavy bombs. 
The fighting was very severe, so we must have got hit with a bomb. 


20 


TRAUMATIC WAR NEUROSES 


I don’t know exactly what hit us myself. I was knocked unconscious 
and I was unconscious for a half hour or more. I was told later that 
■ I got up and walked around the ship but I don’t recall walking 
around at all. I was taken back to the sick bay of our own ship, but 
that was all blown up, too, and there was a British cruiser that came 
up alongside us and they removed those that were most seriously 
wounded. There were eight of us. So the next day we were headed 
back to Scotland, but I wasn’t aware of that until the next day. 

So when I did come to, my head was all swathed up in bandages, 
and my hands. We arrived back in Scotland and I spent two months 
in the Royal Navy Hospital in Aberdeen. 

Dr. Hoch: What complaints did you have in Aberdeen? 

Mr. Lambert: Severe pains in the head. 

Dr. Hoch: Anything else? Were you upset, nervous? 

Mr. Lambert: Yes. 

Dr. Hoch: Can you describe it, in what way you were upset 
or nervous? 

Mr. Lambert: Well, I couldn’t sleep; as a matter of fact, I 
sleep very little yet. 

Dr. Hoch: Did you have dreams? 

Mr. Lambert: Yes, sir. 

Dr. Hoch: Nightmares? 

Mr. Lambert: Yes, sir. 

Dr. Hoch: Can you describe what kind of dreams you had? 

Mr. Lambert: I dreamt of convoys, dreamt of battles, of men 
screaming and shouting. 

Dr. Hoch: Are these dreams very clear? 

Mr. Lambert: Yes, sir. 

Dr. Hoch: Vivid? 

Mr. Lambert: Yes, sir. 

Dr. Hoch: Do you have the impression of being in action? 

Mr. Lambert: Yes, sir. 

Dr. Hoch: Were the dreams colored or black and white? 

Mr. Lambert: Colored. 

Dr. Hoch: You see the thing rather clearly as you saw it when 
it happened? 

Mr. Lambert: Yes, sir. 

Dr. Hoch: What other complaints did you have later on? 
Something happened to your speech, you told me. 

Mr. Lambert: Yes, sir. I stammered and stuttered for quite 
some time; as a matter of fact, I still do at times. 


INTRODUCTION 


21 


Dr. Hoch: You still do at times? 

Mr. Lambert: Yes, sir. 

Dr. Hoch: Immediately after the accident, you couldn’t speak 
at all? 

Mr. Lambert: That is right. 

Dr. Hoch: For how long? 

Mr. Lambert: Oh, quite some time. After getting back to 
Scotland, it kind of cleared up. Upon coming back, I couldn’t talk 
very much at all. 

Dr. Hoch: I see. So your speech difficulty lasted about three 
weeks? 

Mr. Lambert: That is right, sir. 

Dr. Hoch: And then you started to stammer? 

Mr. Lambert. Yes. 

Dr. Hoch: Did you shake? 

Mr. Lambert: Yes, sir. 

Dr. Hoch: What complaint do you have now? 

Mr. Lambert: Well, I don’t sleep very much and if I am up 
for any length of time, say, twelve hours or more without resting or 
sleeping, I begin to see double. 

Dr. Hoch: Yes, you see double with one eye, too; if you close 
one eye you see double with one eye; is that right? 

Mr. Lambert: Not as much as before. 

Dr. Hoch: And you are still shaking at times? 

Mr. Lambert: Yes, sir. 

Dr. Hoch: Were you nervous before all this happened to you? 
Did you consider yourself a nervous person? 

Mr. Lambert. No, sir. 

Dr. Hoch: You were quite calm? 

Mr. Lambert: Yes. 

Dr. Hoch: Did you fear that the ship would be attacked? Did 
you think of that? 

Mr. Lambert: Well, when we first started out, I did for the 
first few days, but that kind of wore off. 

Dr. Hoch: Were you apprehensive? 

Mr. Lambert: Not so much. 

Dr. Hoch: How long are you at sea, for a long time? 

Mr. Lambert: Fifteen years. 

Dr. Blain: Fifteen years. How old are you now? 

Mr. Lambert: Thirty-two, sir. 


22 


TRAUMATIC WAR NEUROSES 


Dr. Blain: You started off pretty young, didn’t you? 

Mr. Lambert: Yes, sir. 

Dr. Blain: How did you happen to go to sea? 

Mr. Lambert: Well, I was young at the time and met a friend; 
he was with the U. S. Shipping Board. He gave me the details and 
I signed up. 

Dr. Blain: When did you get back to this country? 

Mr. Lambert: The twelfth day of December. 

Dr. Blain: What did you do when you first got back? 

Mr. Lambert: I reported to the Marine Hospital at Hudson 
and Jay Street and the doctor there examined me and I said I would 
like to go home and visit my family for a holiday. He said, “Very 
well,’’ and I did, and I got back here in New York the eighth day 
of January. 

Dr. Blain: On the 8th day of January you got back to New 
York after the holidays? 

Mr. Lambert: Yes. 

Dr. Blain: When did you come out to Gladstone? Do you 
remember when you came to Gladstone? 

Mr. Lambert: Yes, sir; that was the 14th, sir. 

Dr. Blain: So two weeks ago, he came out to our place at 
Gladstone. Have you changed any since you got out there? 

Mr. Lambert: Yes, sir. 

Dr. Blain: \\^at has happened to you since you got there? 

Mr. Lambert: I feel better all around, sir. I feel more rested. 

Dr. Blain: You feel better all around? 

Mr. Lambert: Yes, sir; and my nervous condition seems to be 
easing up. 

Dr. Blain: Were you sick any before this accident? 

Mr. Lambert: No, sir. 

Dr. Blain: What had you been doing on the ship? 

Mr. Lambert: Steward. 

Dr. Blain: You were in the steward division? 

Mr. Lambert: Yes, sir. 

Dr. Blain: What were you doing when the ship was hit? 

Mr. Lambert: Second cook, sir. 

Dr. Blain: Where were you on the ship? 

Mr. Lambert: I was near the officers’ saloon. I had the first aid 
station. 

Dr. Blain: You were at the first aid station. Were you warned 
ahead of time? Did you know something was about to happen? 


INTRODUCTION 


2S \ 


Mr. Lambert: Yes, sir. 

Dr. Blain: And there was some warning in this case? 

Mr. Lambert: Yes, sir. 

Dr. Blain: What time of the day was it? 

Mr. Lambert: Around two-thirty or three o’clock in the 
afternoon. 

Dr. Blain: What were the other men like in your boat that 
you went off in? 

Mr. Lambert: Really, I don’t know, sir. 

Dr. Blain: You didn’t know anything about them. How were 
they the following day when you did know? 

Mr. Lambert: I was in the sick bay of this British warship. I 
couldn’t move around. 

Dr. Blain: You can’t tell us how the other men in the lifeboat 
were? 

Mr. Lambert: As a matter of fact, sir, we weren’t in a lifeboat 
at all. 

Dr. Blain: You were picked right off the ship? 

Mr. Lambert: The cruiser came directly alongside us. 

Dr. Blain: So you didn’t observe any of your buddies on the 
ship at all to see how they reacted to all this? 

Mr. Lambert: That is right. 

Dr. Blain: Thank you very much. 

(The patient left the room.) 

I haven’t seen this man myself before. I would like to know 
what neurological condition he had. Perhaps we can find out from 
Dr. Hoch later. We will go on, because I think the other man we 
wanted to present isn’t here. 

Now, we get the impression from our cases that most of them 
give an essentially normal past. If you go into it, you can find some¬ 
thing there, probably; but as a matter of fact that fellow had gotten 
along for fifteen years and he hadn’t had anything serious happen 
to him. 

(The next patient entered.) 

Dr. Sherman: Sit down, please. This is Mr. Andrews, gentle¬ 
men, who was in a torpedo episode on September 27th. There was no 
warning of attack. It occurred very early in the morning. They 
were attacked by what he calls a suicide squadron, consisting of one 
submarine and the activity of the submarine suggests that name. 
The convoy of eighty-two ships was on its way to Iceland carrying 


24 


TRAUMATIC WAR NEUROSES 


general cargo. At the time of the torpedoing, the patient was amid¬ 
ships. He was injured by shell fire, receiving several shrapnel wounds 
of the leg. 

The crew lowered two rafts to get away. The water was very 
cold. Fortunately, they were picked up within a period of about 
fifteen minutes by a corvette and taken directly to Halifax. The 
patient was in the Halifax Hospital for about two weeks, treated for 
shrapnel wounds and for nervousness, was again in the Boston 
Hospital and then came to New York where he was in the Marine 
Hospital for a while and then sent to us. 

Regarding his nervousness, he states he had it really before the 
torpedoing that came at the last. For two trips prior to his last trip, 
he was bothered very much by the depth bombs constantly going 
off around him. The nervousness that he has now became quite 
severe when he came to New York. He finds it very hard to define. 
He says he is very easily upset, with tremor, restlessness and nervous¬ 
ness, particularly on trains. He noticed it this morning coming in 
from Oyster Bay. He has had the characteristic repetitive cata¬ 
strophic dreams that many of these cases have, severe nightmares in 
which he sees the ship being torpedoed and tries to get off the ship. 
The dreams have stopped for several nights and are considerably 
better now, but he still has a good many of these general symptoms 
of diffuse anxiety, severe nervousness. He has a state of what he 
calls extreme worry and wants to quit everything and get away from 
things generally. That is his condition at the present time. 

Dr. Blain: We would like to have him tell us a little bit about 
it. Mr. Andrews, tell us a little bit about yourself, how you feel. 

Mr. Andrews: Well, I am not very much of a talker, you will 
have to excuse me on that point. I am very nervous, doctor, and I 
am very easily upset and especially when I get before people like 
this. 

Dr. Blain: I can understand that. 

Mr. Andrews: Just what do you want me to tell? 

Dr. Blain: Tell us how you felt when you first got nervous after 
this experience. 

Mr. Andrews: Well, when I came to New York, after I left the 
hospital, why I just wanted to get away from everything. In fact, 
when I get on a bus or subway or get around people I feel like I am 
being crowded and jammed into a corner or something, and I just 
want to push everything to one side. I get all upset very easily. 


INTRODUCTION 


25 


Dr. Blain: Does it last long? 

Mr. Andrews: Until I can get by myself and not have anybody 
to bother me, and rest and take it easy. 

Dr. Blain: How long have you been to sea? 

Mr. Andrews: I have been going to sea for nine years. 

Dr. Blain: How old are you now? 

Mr. Andrews: Thirty-three. 

Dr. Blain: How were you before this accident? In good health? 

Mr. Andrews: Yes, sir; perfect health. 

Dr. Blain: Had you been nervous before? 

Mr. Andrews: No, sir. 

Dr. Blain: Did any of the other men have any bad results from 
the torpedoing? 

Mr. Andrews: Yes. 

Dr. Blain: And the bombing? 

Mr. Andrews: Yes. 

Dr. Blain: They did? Tell us a little bit about what you saw. 

Mr. Andrews: Well, one man that went over the side the 
same time I did, he had shrapnel wounds, too. He was very fortunate 
in being fat. He was a saloon messman. He had a piece of shrapnel 
in his stomach approximately the size of a dice box. The only 
thing that saved his life was being fat. 

Dr. Blain: How was that? 

Mr. Andrews: The doctors say—that is the way they explained 
it in the hospital—if it had been a person like myself, a rather thin 
person, it would have killed him. 

Dr. Blain: Did you notice nervousness among any other men? 

Mr. Andrews: Yes, sir; very nervous. 

Dr. Blain: What were they like? 

Mr. Andrews: They were upset and they never liked to talk 
about those things. They were very irritable, the same as myself 
at times. I think I am overcoming that irritability a little bit. 

Dr. Blain: This happened back several months ago, didn’t it? 

Mr. Andrews: Yes, sir; the 27th day of September. 

Dr. Blain: What have you been doing since then? 

Mr. Andrews: I only made one trip. 

Dr. Blain:. You made one? 

Mr. Andrews: Yes. 

Dr. Blain: Coastwise? 

Mr. Andrews: A 29-day trip. 

Dr. Blain: How did you get along there? 


26 


TRAUMATIC WAR NEUROSES 


Mr. Andrews: Not so good. 

Dr. Blain: Tell us how you were. 

Mr. Andrews: We didn’t have much trouble. It broke out once 
or twice. I remember the first time very distinctly, because the time 
we got the general alarm it was at night, around nine-thirty or ten 
o’clock. I was in my bed and it was the first alarm heard since I was 
torpedoed, and I practically froze in my bed. I didn’t want to get 
out. 

Dr. Blain: You couldn’t move? 

Mr. Andrews: In other words, I was muscle-bound, you might 
say, for several seconds. 

Dr. Blain: How long between the time you got back and the 
time you shipped out, two or three weeks? 

Mr. Andrews: No, sir; it was longer than that, approximately 
a month. 

Dr. Blain: About a month later you shipped out yourself? 

Mr. Andrews: Yes. 

Dr. Blain: What did you do during that month? 

Mr. Andrews: During that month? 

Dr. Blain: Yes. 

Mr. Andrews: Well, I was in the hospital two weeks and I 
came down to New York and I went down to Philadelphia. 

Dr. Blain: Did you feel nervous during that month? 

Mr. Andrews: Yes, sir. 

Dr. Blain: You felt nervous the whole month, but you shipped 
back anyway? 

Mr. Andrews: Yes. 

Dr. Blain: Did anybody talk to you about war nerves at all? 

Mr. Andrews: No, sir. 

Dr. Blain: Nothing like that? Therefore, Dr. Sherman is 
the only one that has explained anything like that to you at all. 
Has he explained anything to you? 

Mr. Andrews: Yes. 

Dr. Blain: How long have you been out there at Oyster Bay? 

Mr. Andrews: Tomorrow will be two weeks. 

Dr. Blain: Did anything happen to you since you got out, 
have you gotten worse? 

Mr. Andrews: No, sir; I feel very good. Of course, now I am 
nervous today, naturally. I came over to the city yesterday. I had 
business in Bayonne, New Jersey, and the business I had took me 
all day and upset me quite a bit and I didn’t get in until late yester- 


INTRODUCTION 


27 


day afternoon. However, I got a good night’s sleep and felt rather 
good this morning when I got up. 

Dr. Sherman: Your sleep has been considerably better, hasn’t it? 

Mr. Andrews: Yes, sir. 

Dr. Blain: Does anybody have any questions? This gentleman 
has had certain experiences and is able to express himelf pretty 
well, I think; if not, we are very much obliged to you for coming, 
and we hope to learn from these doctors here how to do even 
a better job on you. 

Dr. Sherman: This is Mr. George Weston, gentlemen. 

Dr. Blain: How do you do, George. Have a seat. We are 
very much obliged to you for coming. 

Dr. Sherman: Mr. Weston was in a torpedo episode in May, 
1942. He was asleep at the time of the explosion which occurred 
at five o’clock in the morning. He jumped up and found his 
berth was all torn up. The doctor said later that he must have been 
blown out of bed in his sleep and then came to afterwards. He 
got to deck all right and made the last lifeboat off the ship. There 
was heavy shelling of the ship and he was excited and was not 
frightened at that time. His symptoms began immediately after 
the torpedo experience; about ten minutes after the submarine left 
the scene, he had severe headache and had body image disturbances 
and his head felt as large as a chair, as he describes it. He was unable 
to stand up. Later he had hand tremors. I suppose he still has them 
a little bit. There was a pendulum pain in the left side of the head 
followed by depression, quite severe; weakness of the wrists; the 
hands were stiff; paresthesia of the palms, which felt very thick. 
There was a severe delayed fright reaction which came a month 
after the disaster when he was in a parade in New York, sitting 
next to a man on a parade float. This man had been in the tor¬ 
pedoing with him, and this reaction was followed by diffuse anxiety. 

The patient still has considerable anxiety. He has this tremor 
of the hands. He has the stiffness, the wrist weakness, and he has 
been worried considerably over a cisternal puncture which he had 
at one of the hospitals before coming to the rest home. 

He has quite an unusual past. He was born in Antigua, British 
West Indies; went to sea very early in sloops, one-masters, and cargo 
vessels; was coal passer and deck man; married at 32, settled down 
in Boston, took night school courses and educated himself, is ex¬ 
tremely well-read, a student of English and history. He did Negro 


/ 


28 TRAUMATIC WAR NEUROSES 

uplift work for many years, was cook for the New York Central Rail¬ 
way; organized a union and was discharged from the railway after 
that; went back to sea at the onset of the war, as he says, to make a 
contribution. 

How are you feeling now? Do you feel you are any better since 
you got out of the hospital? 

Mr. Weston: Not much better, with the exception I don’t have 
the headaches so regularly. 

Dr. Sherman: The kind of headache you described before is 
not as bad as it was? 

Mr. Weston: No, sir. Since I left the hospital, I had headache 
about ... I left the hospital last Wednesday. 

Dr. Sherman: Will you describe that feeling you had shortly 
after the submarine left the scene when you were lying in the boat 
and your head felt so strange? Could you describe that, do you 
think? It was kind of swollen feeling, wasn’t it? 

Mr. Weston: Well, I Avasn’t expecting such a gathering here 
when I came in. I am somewhat off my equilibrium, so you will 
pardon me if I hesitate sometimes. I can’t make any contact with 
the things I want to say. And since I came in here and saw so many 
people, I didn’t knotv whether I was before the Fuehrer, whether I 
would go in and find the Fuehrer or II Duce waiting for me, for 
having said what I said some months ago. So you will give me just 
a minute to gather my wits. 

I explained to the doctor that ther.e is a slight recollection regard¬ 
ing being thrown on the deck. It wasn’t just that statement; the 
doctors told me when I said I woke up, that I must have been 
knocked out in my sleep and I came to. I thought I woke up. That 
is, I came to. That Avas Avhat they told me in the hospital up in 
Maine. 

I wish I had a friend of mine Avith me who did rescue me, the 
man who came back in the lifeboat for me, because he could tell you 
something that actually frightened me, doctor, a week after I left 
the hospital, just after I left you to come in and go to the neurolo¬ 
gist. He came to my house and he told my wife that he didn’t know 
how it was possible that I got out of that room, because when I stood 
at the rail of the ship and called at him, "Countryman, come 
back here and let me get in that boat,” he said he thought I was a 
spirit, because he had been trying to get to that side of the ship, and 
where I slept was a mass of tAvisted steel and blaze coming up over 





INTRODUCTION 


29 


there, and he had to turn back and go around the other way to get 
to the lifeboat. And when I came out there, he thought that I was 
a spirit. So I looked at him and said, “Is that risrht?” 

He said. That is right. I couldn’t believe you had rotten out 
of there.” 


He even said. It is too bad”—they called me Doc. I don’t know 
for what reason. He said, “It is too bad Doc slept in this room 
because he is really gone.” And when he saw me appear on the rail 
of the ship and I hailed him, he thought that I was a ghost. 

Now, when I woke up, what woke me was just the same as if 
you were sitting in an automobile and someone stepped on the run¬ 
ning board and you were looking in an opposite direction, and jiist 
that slight movement caused you to turn. It was just that that woke 
me up. I woke up and I heard as I /woke, “Lower away, lower away, 
lower away,” and I wondered. I looked out the porthole, because 
there was a porthole right over my berth. I looked out and I didn’t 
see anything extraordinary. So I reached up to turn the light on. 
I turned the switch and there was no light, so I turned the bulb, and 
there was no light. You see, the other cook who slept in the room 
with me—I was the chief cook and he was the second cook—when he 
was leaving the room (they never slept in the room at night; I always 
slept in my room) he would turn the switch or turn the bulb. So 
I turned the bulb. I turned the switch and there was no light. I 
turned the bulb; there was no light. I said, “Huh-huh, something 
has happened.” 

In the meantime, I had felt that things didn’t feel right. Every¬ 
thing was all torn up, even my berth was ripped slightly and 
my head was somewhat down. But I was as conscious as I am now, 
and I felt under the berth where I had my things, shoes and stockings, 
so if anything would happen I would have them handy to get to 
them. Everything was scattered all around and I felt all around 
there. I found two shoes, and they were two left feet shoes. When 
I got in the boat, I found out. I didn’t know what they were then. 
I put them on and I got my life preserver which, by the way, was a 
private life preserver I bought in Buenos Aires last January when 
I was there. I bought it there, and it kept me up 37 hours and kept 
sharks away from me. I have it home now. 

I put that on and I found my way. I can’t even tell you now 
how I found my way up to deck. And when I got up, I saw the 
chief mate trying to get things together. He had a bag and his 


30 


TRAUMATIC WAR NEUROSES 


searchlighti in his hand, and I said, “What is the matter? Have we 
been hit?” 

Of course, he used the sailor’s language to tell me that we were 
hit. He said, “You bet your boots we were hit.” Of course, there 
was the sailor’s language included therein. 

Dr. Sherman: Tell a little something of the shell fire. 

Mr. Weston: After I got into the boat, they took me in the 
boat. I got in the boat. The submarine came to the surface and 
everybody was excited in the boat at the time. All of a sudden 
they got quiet and I heard whispering, “There is the submarine. 
There is the submarine.” They were hollering previous to that, and 
they were saying, “There is the submarine,” and everybody looked 
and kept quiet. Then the submarine shot out and shelled the ship 
over our heads. There were seven shells fired. I can remember 
very, very well. I counted them. And one of them missed, but six 
did trike the ship and in less than a second or two she went down 
and the submarine disappeared. 

We pulled around for a few minutes and soon after that my head 
began to grow very, very large, and I couldn’t sit up, and I com¬ 
menced to throw up in the boat, and I had to lie down. I lay there 
for a long time. I was in the stern sheet of the boat and there was 
no one who could steer the boat while I was sitting there, so they 
gave me the oar and I was steering the boat this way, with the oar 
over my head, (demonstrating) for a while. Then another man 
took the oar and started steering and I shifted my position over to 
the other side of the stern and the submarine went away. At least, 
the submarine had gone then. 

Dr. Blain: What do you think you are going to do with your¬ 
self? Are you going back to sea again or back to Boston? 

Mr. Weston: As soon as I am healed, I propose to go back to 
sea. Of course, my wife is objecting to my going back, but I still 
want to go back. 

Dr. Blain: We are very much obliged to you for coming. You 
told us a lot of interesting things. 

Mr. Weston: I am sorry if I wasn’t as clear as you expected me. 

Dr. Blain: You were very clear. You did very well. (The 
patient left the room.) 

We feel that these people are coping first, with more or less of 
a normal reaction to a dangerous situation. The body-mind machine 
reacts in ways suitable to the animal level but often inappropriately 


INTRODUCTION 


31 


where defense instincts are not allowed complete sway. Physiological 
response often interferes with escape raiier than helps it. The 
reaction may be overwhelming and give the appearance of a serious 
mental condition. Sufferers in this condition obviously need hospi¬ 
talization, if possible. 

It may be some time before this normal response to the immedi¬ 
ate danger becomes connected with past experiences or joins with an 
earlier neurotic pattern. 

Hence, normal people are vulnerable and react in a simple 
fashion. Those with neurotic background, we feel, may also react 
simply to the war experience and this reaction is not at first part of 
the life pattern. 

Traumatic neuroses in war seem different from civilian neuroses 
because of the overwhelming danger in the war situation not found 
in times of peace. Although all the men I saw had been torpedoed 
some weeks before, they apparently had not yet settled down to any 
mode or place of living, hence could still be considered in “an early 
stage.” The incipient neurosis encapsulated a surface phenomenon. 

From this general idea developed the whole plan of treatment. 
Acute situations would be treated in the Marine Hospitals but we 
would advise withdrawing them as quickly as possible. From then 
on we determined to keep the condition entirely separate from other 
diseases, or the atmosphere of disease—in other words, from both 
general hospitals and mental hospitals. We would avoid all psychi¬ 
atric terminology, call the condition “war nerves,” a name with a 
non-affective connotation, speak of the problem as being strictly 
medical, call the psychiatrist the doctor, keep the nurses out of 
uniforms and substitute the designation of home for hospital. Our 
concept of pathology was possibly oversimplified in the idea, “He 
acts as if he were still in the midst of the danger situation.” Our aim 
might also be simplified by, “Build him up, get rid of his symptoms, 
send him out as soon as possible with something definite he can use 
in the future.” 

This implied that he must go through with what he had—an 
educational process for both insight and knowledge useful in the 
future. 

The habitual shrinking of body resources and the loss of self- 
confidence (ego) produced by the traumatic incident must be 
treated directly with every available tool. Hence food, vitamins, 
rest, massage and physiotherapy, sedation, exercise and suitable 
recreation on the one hand and personal attention, intelligent 


32 


TRAUMATIC WAR NEUROSES 


interest and sentimental sympathy, well-founded reassurance, a 
doctor with good strong personality to lean on, a chance to discuss 
personal affairs privately and an accumulation of knowledge about 
one’s self are the keystones of treatment. 

These ideals are incorporated in our convalescent homes, of 
which we have five scattered over the country. If the men average 
three weeks, which they do so far,we can take care of 4000 a year, 
which I think is just what we need. 

A compromise between small groups for personal attention and 
homelike atmosphere and larger numbers to lessen the cost per 
patient has set the optimum number in a rest home at 35 to 50. 

The staffs have been kept small, the chief administration control 
of patients in the hands of a competent psychiatric head nurse, assisted 
by one or two nurses with general duty training. A secretary and 
business manager were chosen for personality and experience to help 
in the general program. For occupational therapy it was planned to 
get the men interested in jobs of repair, wood cutting, cleaning up 
and other chores usually found in a country place. It was first thought 
that nurses, business manager and superintendent could direct both 
work program and recreation and trained specialists would not be 
necessary. 

It was warned that medical personnel would be impossible to get. 
However, these homes would be near large ports, where psychiatrists 
are usually found in greater numbers, and I knew of the tremendous 
interest civilian doctors had in war neuroses and I knew that every 
civilian was desperately anxious to get into war work. To conserve 
medical time, group talks to the men were started the first day on 
topics concerned with anatomy, physiology and emotional condi¬ 
tions, and often subjects requested by the men themselves were 
discussed. It was my habit at the first home to invite all the stafiE, 
including domestics and any visitors, to come. In this way the whole 
group became educated in a psychiatric point of view and this alone 
has contributed greatly to a harmonious atmosphere. 

I estimated that one doctor on half-time could do the treatment 
if he spent three whole days each week. Hence I counted on getting 
my doctors from civilian psychiatrists, having them appointed as 
psychiatric consultants by the Public Health Service. I believed I 
could use women as well as men. So far my expectations have been 
justified and I have a competent staff at each home. I planned also 
to have a supervisor for each port who would oversee the work and 
organize a psychiatric clinic for those who had to stay in the city. As 


INTRODUCTION 


33 


you have been told, I have asked nearby medical schools to become 
associated with these places so as to get help and guidance for the 
staff of the school in order to guarantee good medical work; also 
to let them have access to good teaching material. My staff has given 
lectures in war neuroses to many student groups. We are ready to 
conduct courses using our material and experience for groups of 
doctors, psychologists, and social service workers, and plan to start 
the first course of training for volunteer nurses in war psychiatry. 

A most important unit is our contact force of medical social 
workers. Each port has a representative of our department to handle 
admissions and follow-up work. Each admitting office is manned 
by a medical social worker and she brings to bear all the help from 
welfare and seamen’s agencies and uses a corps of volunteers to 
accomplish a great deal for our men. Local social committees take 
care of providing entertainment. 

Prevention is the ideal of any such program as ours. Generally 
speaking, the treatment that we give would be essentially what we 
would recommend if it could be applied in advance of the traumatic 
episode, and by this I mean not only the acute danger action, but a 
prolonged anticipation of such action. So far we have been unable 
to do more than theorize on the psychological first aid which should 
be given immediately when “war nerves” begin. We are at this 
moment preparing educational material for our seamen, to prepare 
them for the dangers ahead. The training in psychological first aid 
will be accomplished by lectures, special courses among the men 
on active duty, and printed material circulated on all ships and 
among all personnel of the Navies who will be likely to pick up sur¬ 
vivors. We would appreciate any suggestions along this line. 

Large recreation camps in order to boost morale and get the men 
ready to return to sea after long voyages in a less vulnerable condi¬ 
tion are already part of the War Shipping Administration’s accepted 
plan. 

I believe the concept of a small, carefully picked staff with 
experience in mild emotional states and an interest in therapy rather 
than hospital adminstration, plus wide use of the desire of the 
public to have a share in the war, are the most important parts of 
our plan. 

Needless to say, I have been given great freedom of action by my 
chiefs in the War Shipping Administration and every backing by the 
United States Public Health Service. We are here to broaden our 
concepts and get advice on improving our program from you gentle- 


/ 


/ 


34 TRAUMATIC WAR NEUROSES 

men who have so kindly accepted Dr. Parran’s invitation. 

Chairman Parran: Thank you, Dr. Blain! 

As you note from the program we have listed three sections, the 
first on etiology and pathology; the second on treatment, and the 
third on prevention. We have asked for the first section Dr. Earl 
D. Bond of the University of Pennsylvania to take over and act as 
discussion leader. 

Dr., Bond will come forward and take my place here and we will 
proceed with the first topic. 

(Dr. Bond assumed the chair.) 




ETIOLOGY AND PATHOLOGY 


/ 


) 


ETIOLOGY AND PATHOLOGY 


Chairman Bond: The opening discussion of this section on 
etiology and pathology will be given by Dr. Paul Hoch, whom you 
have met already. Dr. Hoch! 

Dr. Paul H. Hoch: Ladies and Gentlemen: The ideas on the 
etiology of the traumatic war neuroses have undergone considerable 
changes. Not many reports are available about the occurrence of this 
condition before the first World War. In the beginning of the last 
war, it was assumed that the conditions now called traumatic neu¬ 
roses were caused by microstructural lesions in the nervous system. 
Oppenheim claimed that the “shell shock” produced a concussion 
which damaged the brain tissue physically, as in certain cases of 
head injury. 

This theory was disproved later in the last war by the evidence 
that many patients developed “shell shock” without being near explo¬ 
sives and that many recovered when removed from the danger zone 
or when they came under the influence of suggestive treatment. Since 
then, more and more emotional elements were discovered in the 
pathology of the war neuroses. The organic etiology was abandoned 
and replaced by theories stressing the psychic origin. Different auth¬ 
ors emphasized different aspects of the emotional causation. Most 
of them, however, assumed that a conflict existed between the sense 
of duty on the one hand, and the escape from danger on the other 
hand, which was solved unconsciously by a flight into illness. A 
primary gain of the traumatic neuroses was the desire to be removed 
from danger, in many cases progressing into a secondary stage of 
wishing to receive compensation or pension. 

Freud believed that the self-protective mechanism breaks in these 
individuals and that the psyche is overwhelmed with stimulation with 
which the person is unable to cope. This inability produces anxiety 
states with diversified sylnptomatology. 

Kardiner, on chronic case material, arrived at similar conclusions, 
believing that due to the trauma the person loses control of the 
situation, which causes lasting damage to the person’s appraisal of 
his relationship to the outside world. He perceives the outside 
world to be hostile toward him. He tries to protect himself against 
this hostility. Rado again emphasizes that the emergency control 
breaks down in these persons and that unconsciously the trauma 

37 


38 


TRAUMATIC WAR NEUROSES 


.fulfills the desire of the person to be removed from danger. The 
fear of war is later transformed into fear of life in general. He calls 
this reaction “traumatophobia.” 

All these ideas are certainly valid. Still, they do not explain the 
development of all traumatic neuroses. It is impossible at present to 
evolve one etiology, treatment, and prognosis for all known types of 
these disorders because the individual variations are very great, as 
anyone working in this field knows. We were struck, in our own 
material, by the inability to work out a common denominator for 
all instances. 

The causative factor in the traumatic war neuroses is not very 
complicated and is common to all. This causative factor is the war 
with its deprivations, horrors, and discomforts, which provokes the 
mobilization of all the available mechanisms of self-defense. All 
this wears down the person physically and mentally. It is obvious 
that the causation is not based on one factor, but that there are 
many variables in the physical and mental field which have to be 
taken into consideration. And even the constellation when, where, 
and how the trauma happened, is of importance. All this makes it 
difficult to generalize or to compare one group of patients with 
another. In some of our cases it was apparent that the physical factor 
played a great role. Men, after being torpedoed, were in lifeboats, 
sometimes well over a month, lacking food and water and developing 
states of exhaustion. The traumatic neurosis which was not present 
in the beginning, developed after their resistance was lowered. In 
others, emotional factors played roles which were as capable, owing 
to the rising tension and apprehension, of producing exhaustion as 
physical effort. For instance, if the man was not well adjusted in 
the group in which he served, or if he was anxious about supposed 
laxity in safety measures, or if he was not treated squarely. In addi¬ 
tion to the anxiety, a great deal of hostility was built up which con¬ 
tributed to the breakdown of the person. 

We had men who, in the early phase of the neurosis, talked 
in a paranoid way about how the safety measures were inadequate, 
or that the skipper of the ship did not behave properly, or that they 
did not receive the proper attention when they arrived on shore. Dr. 
Blain has collected a number of such cases. We believe that this 
anxiety element is very important in the development of certain types 
of traumatic neuroses, and that the men should have what we call 
a “preventive assurance” that everything is done and will be done to 
assure maximum safety and security under given circumstances. 



ETIOLOGY AND PATHOLOGY 


39 


These factors already mentioned are especially at work in the type 
of traumatic neuroses which develop slowly. In many of our men, 
however, the traumatic neurosis did not develop after a period of 
physical or emotional exhaustion. It developed suddenly under the 
impact of an overwhelmingly terrifying experience. In this group 
of persons the trauma produces an emotional shock, as a gross bodily 
injury provokes a somatic shock. The emotional shock has, too, a 
tremendous impact on the “self-government” of the individual, 
which collapses totally or partially and is replaced by a state of an¬ 
archy that disorganizes the normal balance of excitation and inhibi¬ 
tion in the organism. This disintegration of self-government 
manifests itself in three different ways. 

1. Emotional storm. (Terror state, which leads to narrowing of 
consciousness, amnesia, confusion, or, in others, to stupor or 
excitement). 

2. Mobility storm. (Trembling, shaking, or when inhibiting 
mechanisms have the upper hand leading to immobility and 
cataleptic states). 

3. Vegetative storm. (Affecting all parts of the body but mostly 
evidenced by alteration in the sleep-function, in the function of 
the heart, or diarrhea, vomiting, anorexia and other vegetative 
symptoms). 

This chaotic, catastrophic anxiety state is a primitive defense re¬ 
action which overshoots the mark. It is similarly observed in animals, 
as it was demonstrated by Pavlov, Cannon, Liddell and others. In 
this elementary phase of the traumatic war neurosis, not much con¬ 
flict or gain can be detected. Complicated mental mechanisms 
ceased to function. 

That such an anxiety state is not altogether purposeful is shown 
by some of our men who were so frightened that they had to be 
pulled out by'others. Otherwise they would have died. 

In some persons this terror state does not set in immediately 
after the accident. During the race with death they function auto¬ 
matically, but collapse after the exertion. A few of our cases behaved 
this way. 

After a while this anxiety storm subsides and then the person 
begins to take stock. This leads into the second stage of anxiety. 
Many of his infantile fears become activated. He thinks about 
death. He perceives many strange sensations due to the disturbed 
integration of his body function. The main difficulty however, is 
that he does not have himself in hand. “I lost my grip,” “I am 


40 


TRAUMATIC WAR NEUROSES 


unable to control myself,” as our men express themselves. Conflicts 
about duty and escape may enter in this phase of compensation. 
Slowly, this still flexible condition becomes fixed, and then all the 
mental pictures occur which are so well known in the chronic patient. 
We do not want to pay attention today to the chronic patients 
because we believe that our therapy should get in immediately, as 
in a surgical shock case. The first anxiety phase is a psychosomatic 
entity and has to be attacked with new methods of sedation^or even 
anesthesia along with psychotherapy. 

In our material the so often discussed amnesia factor appears to 
be unimportant. Many patients want to forget, and I think this 
tendency should be supported. Some of our men used alcohol fairly 
successfully to obtain this end. Only a few patients want to recall 
every detail of the accident. This effort to recollect becomes like 
a compulsion. The recall of events in such instances is helpful. 

It was and is maintained by some investigators that the premorbid 
personality is the most important factor in the development of war 
neurosis. No doubt, in the traumatic neuroses of civilian life this 
holds true, and no doubt that even in a group of war cases previous 
personality changes could be tracked down. The vast majority of 
traumatic war cases will not show an abnormal hereditary back¬ 
ground, and their personal histories will show good adjustments 
before the trauma (Bowman). 

In our cases all kinds of persons developed similar reactions, with 
different physical constitutional make-up and personality traits. It 
was furthermore most surprising that if abnormal traits were found, 
they had no relationship to the recovery. 

Among the Merchant Marine personnel are many abnormal per¬ 
sonalities. Many of them went to sea to escape organized society or 
land. Many are alcoholics, having sexual and other maladjustments. 
Probably these morbid traits force these individuals back to sea, 
counterbalancing the desire to remain in a war neurosis. I am con¬ 
vinced that many of these individuals would have been screened out 
as unfit for military service because of a pre-morbid anamnesis. 
These same men show a strong tendency to recover after being ex¬ 
posed to very harrowing experiences. There are naturally other 
factors which put the seamen in a different category. Their services 
are voluntary, many are oldtimers in this profession, and what is 
most important, they are not entitled to a veteran’s pension. But it 
shows that an abnormal personality does not necessarily lead to a 
breakdown or foster the tendency to remain sick. 


ETIOLOGY AND PATHOLOGY 


41 


Ladies and gentlemen, there are still great gaps in our knowlege. 
Why one person breaks down and the other not, is still a puzzle. Why 
one person recovers quickly, and others not, is again not well known. 
Why one person displays a hysterical form of reaction, the other an 
anxiety state, and why the third develops a gastric ulcer, is only 
scantily understood. 

The susceptibility of individuals to emotional trauma is as 
varying as to infections. These differences we have to investigate. 
We believe that some of the gaps in our knowledge will be filled by 
today’s discussions, others will be solved by future research. 

Chairman Bond: Is there discussion on this subject of etiology? 

Dr. a. a. Brill: I was very interested in what Dr. Hoch told us. 
As he said, he didn’t tell us anything very new. Those ideas have 
been expressed by various authors, but all I wish to say is this: The 
first case of war neurosis that I saw during the last World War, that 
is, before we entered the war, was an English army officer who was 
sent to me. After I worked with him for about two months, I found 
out that he was nervous long before he went into the war. In fact, I 
thought that he came to me accidentally, but I found out later that 
for years he had my address. He kept it with him, and mind you, he 
was an Australian. ‘ 

Well, then, since that time I concluded—and not just from this 
one case; I have been connected with the United States Facility 81 
since the hospital started; I have analyzed some cases from there and 
a great many in private practice—those cases are ordinary cases which 
we are wont to call traumatic neurosis. As Dr. Hoch pointed out, 
their symptoms are different because we deal with different 
personalities. 

“As many men as many minds.’’ And different people express 
themselves differently, and the difference in the symptoms is due to 
so many things. I don’t wish to indulge in any technical terms and 
say this kind of homosexual components, that kind of behavior.' But 
each one has something to show which is different from the other. 
I would like to be able to leave here today and find something 
definite and special. I hope you will show it to me. 

Dr. Edward A. Strecker: Dr. Bond, I am particularly inter¬ 
ested in this phase of the discussion. Unquestionably the etiology 
and psychopathy of “combat fatigue” (which we have agreed to call 


42 


TRAUMATIC WAR NEUROSES 


these conditions), is very deep and very profound. Of course, it 
must involve general etiological and psychopathological factors. In 
addition, highly personal factors must be implicated. However, 
within the limits of authenticity, the simpler the hypothesis, the 
more effective will be the therapeutics. It would seem to me, too, 
that the infomation we uncovered about so-called war neuroses or 
“shelf shock” in World War I has a great deal that is transferrable 
to the present situation; that effective therapeutics will flow from 
the simple visualization of the emotional conflict: on one hand the 
danger situation, and also the thoughts and motivations grouped 
together and called Merchant Marine ideals. You have here a rather 
simple, workable hypothesis: a case of combat fatigue is the patho¬ 
logical compromise of the conflict between the dominant instinct 
of self-preservation and the danger and hazards incident to service 
in the Merchant Marine. 

One thinks at once of the possibility of strengthening the second 
limb of the conflict. In the case of the soldier we think of adherence 
to tradition and discipline, desire to acquit one’s self favorably, and 
many other things. It is not difficult, although far too little recog¬ 
nition is now being given to it, to visualize the Merchant Marine in 
this war effort as tremendously important, loyal, patriotic and exceed¬ 
ingly hazardous. In addition to the two units of the emotional 
conflict, there is usually a precipitating occurrence, whether it be 
concussion—I mean non-traumatic concussion—or exposure, depriva¬ 
tion, or something else. 

Now, I do think that this hypothesis was fruitful in therapeutics 
of the war neurosis in World War I, and I see no reason why it 
should not be effective in the particular situations under considera¬ 
tion. We attached a great deal of importance to the amount of 
befogging of consciousness and it was our feeling that in a way 
the greater the disturbance of consciousness the better the outlook 
for the particular therapeutics of the case. 

Chairman Bond: Dr. Kardiner’s name was mentioned in the 
opening discussion. Dr. Kardinerl 

Dr. Abram Kardiner: I was very glad to hear Dr. Hoch’s 
report, because it is a confirmation of an idea that I have tried to 
propound for years without much success. Dr. Hoch said that he 
found no consistency in the pre-traumatic personality. I wish to 
support him in this contention. You can find every variety of pre- 


ETIOLOGY AND PATHOLOGY 


43 


traumatic personality and, so far as I know, there are only a few 
criteria that we can use to indicate the kind of person that is certain 
to get a traumatic neurosis when exposed to the conditions of war. 
They are not very numerous. Stammerers are excellent candidates 
for traumatic neurosis; anybody with a history of stammering is 
bound to succumb sooner to shock than any others. People with a 
history of chronic autonomic disturbances do so likewise. But I 
can state with absolute assurance that anybody who has at any time 
in his life had a disposition to epileptiform reactions of any kind, 
be it in childhood or later, is found to succumb to a traumatic 
neurosis. 

One of the reasons why we have great difficulty in solving the 
problem of predisposition is that we don’t know precisely what to 
look for in the preceding history. 

All systems of psychopathology that we have today tend to go 
in the direction of exploring the social relationships of the human 
being, and I can tell you, having studied this problem for many 
years, that it is a fruitless quest to derive the traumatic neurosis 
from disturbances in social relationships. This neurosis is a dis¬ 
order of the executive system for action, and hence is a much more 
primitive reaction than the ordinary hysteria. Those whose neuroses 
depend upon defects in their social relationships, do not develop 
this particular kind of reaction. They develop the ordinary hysterias 
or compulsion neuroses or what not. It, therefore, behooves us to 
look in another direction, and I can only indicate the general 
direction, in which it may be found; I cannot tell you with any 
specificity. 

I think that the predisposition to the traumatic neurosis is to be 
found .in certain types of maldevelopment in the accommodation 
of the individual to the external world. I have this hunch largely 
because of some of the most severe cases of traumatic neuroses in 
which this part of their history seemed affected. What I mean by 
that is this: As children, these individuals with the traumatic neurosis, 
do not play like other children. They have a tendency to be over¬ 
destructive, which means, in effect, that mastery techniques were 
retarded. This was the only criticism that I was able to establish 
in the childhood of these people who developed traumatic neuroses 
later. 

Now, I should like to take issue with Dr. Hoch on one point. 
He stated that the primary reaction of the traumatic neurosis is a 
defensive one. If so, it is a disorganized defense. The third symptom 


44 


TRAUMATIC WAR NEUROSES 


is disorganization, and disorganization is followed by an attempt 
of the individual to withdraw not only from the danger situation 
but from everything else which he now identifies with the dangerous 
situation. The pathology depends upon the persistence of this in¬ 
hibitory reaction and, therefore, he is unable to reestablish the 
control that formerly existed. 

I should also like to take issue with Dr. Hoch on the subject 
of the amnesia. The amnesia is only one minor symptom of the 
whole thing, and in a large number of cases it acts as a bell-wether 
of the progress of the whole case. There are some cases wherein 
you can recover amnesias and nothing will happen, and in other 
instances the recovery of the amnesia is an absolute essential for 
the recovery of the patient; simply because he indicates by the 
ability to recover the amnesia that he no longer needs this protective 
device of forgetting or withdrawing from the environment. So it is 
an indicator of recovery rather than a means of effecting it. 

Dr. Howard Rome: I have had the opportunity of confirming 
Dr. Kardiner’s observations in a somewhat different group. I have 
seen the Marines, who have been stationed on islands in the South¬ 
west Pacific, the isolation of which is obvious. Those who had 
traumatic neuroses acquired in combat were subjected to bombing 
during the day and to field maneuvers at night and were conse¬ 
quently unable to escape a chronic frustration and its resulting 
tension. 

Dr. Lawrence S. Kubie: My impression is that a delayed re¬ 
action to the torpedoing is not basically different from an immediate 
disturbance; because a careful investigation shows that the upset 
was brewing, but that the individual had been able to suppress the 
symptoms and to maintain certain compensatory functions during 
the interval. Therefore, I am going to take it as my working 
premise that the immediate and delayed disturbances are identical. 
Naturally, superimposed upon these primary reactions, whether 
immediate or delayed, a slow accretion of complex secondary symj> 
tomatology can go on for weeks, months, or even years. Into this 
secondary structure flow confluent streams from every aspect of the 
individual s life. This, however, is no longer a primary reaction to 
the experience alone. It is a latent civilian neurosis, ignited by 
the primary neurotic reaction to the trauma. 

The primary reaction, itself, can be divided into two essential 


Etiology and pathology 


45 


components. One evolves directly out of the panic of the experience. 
The other follows soon after in the form of a haunting depression. 
This depression is described by almost everyone who has been sub¬ 
jected to prolonged experience of this kind. It does not occur 
where the experience is over in a few hours, but only where it is 
long drawn out. The men in “The Raft,” for instance, describe 
a cloud of deep and poignant gloom which would settle over them 
periodically for months after their rescue. 

I emphasize this haunting depression, because it is usually over¬ 
looked and because it is of special significance in the neurosis 
among seamen. The seamen of the Merchant Marine are in certain 
respects a group apart. Although one must agree with Dr. Kardiner 
that the multiplicity of the human factors underlying the traumatic 
neuroses must be kept in mind, yet there is something common to 
this group of men which emphasizes the depressive component in 
their traumatic neuroses. In the first place, most of these men have 
gone to sea very early in life partly to escape ordinary home ties. 
Except for the Negroes and the Latin Americans, relatively few 
of them are married. Furthermore, they form limited human rela¬ 
tionships with their fellow-seamen. During a trip their bonds to 
one another are often friendly and warm; but these ties are usually 
severed at the end of each trip. Only exceptionally do individuals 
pair up as buddies and ship out together. Thus, their relationships 
to one another are shadowy and transitory. The same forces which 
early in life drove them away from home make sustained friend¬ 
ships impossible later. As a result, they become for one another 
the repositories of all kinds of unconscious feelings drawn from 
childhood. They are objects of strong but temporary attachments, 
of close identifications, and of sharp but masked hostilities. That 
is precisely why their bonds are transitory. And that is also why 
when shipmates are injured or drowned before their eyes it is inevit¬ 
able that they go into depressions in which they are haunted by 
feelings of guilt, as though their survival was at the expense of those 
who were lost. Indeed, this is the constant content of the depres¬ 
sions which arise after this type of experience. It is intensified by 
the traditional attitude of “every man for himself,” which is accepted 
when the order comes to abandon ship. So much for the element 
of depression. 

The element of panic in the primary upset is the most general 
reaction to all traumatic experience. It arises when the friendly 
sea suddenly becomes the seaman’s deadly foe. It is not merely 


46 


TRAUMATIC WAR NEUROSES 


because there is no avenue of escape, but also because every familiar 
object around him has become his enemy. Yet the seaman is a 
seaman because he feels safer at sea than on shore: more relaxed, 
less tense, less restless. So true is this that in some cases men who 
have been through repeated harrowing experiences have said in 
perplexity, “I don’t know why it is, but when I am on land, I get 
the jitters. When I get on a boat, as soon as the engines start, I 
feel all right, even though I know that I am going back to the 
same danger.” So great is the emotional power of the fantastic 
significance of the ship and the sea that it blankets the norrnal 
reaction to the anticipation of real danger. 

But at the moment when the ship is torpedoed, it is as though 
their haven of security had suddenly turned on them. At that 
moment the man becomes paralyzed, because he cannot move in 
any direction without facing terror. This is characteristic of every 
situation in which anxiety becomes a paralyzing force instead of 
mobilizing and freeing effective action. Subsequently this pent up 
terror state gives rise to nightmares in which the sailor relives the 
terrifying experience in an effort to find a happier ending. His 
mounting terror wakens him each time; and in time this repeated 
experience leads directly into the evolution of the full fledged 
traumatic neurosis. 

Chairman Bond: Dr. Kubie has opened up an interesting side 
to this. Is there further discussion? 

Dr. Sandor Rado: I fully agree with Dr. Strecker that the con¬ 
flict between military duty and self-preservation is the psychological 
background of the war neuroses. However, this theory is yet too 
vague to guide us in prevention and treatment. We may make it 
more specific and thereby more useful if we realize that the organism 
is equipped with an integrative system, “emergency control,” which 
regulates its behavior when it is exposed to injury. The classical 
investigations of Walter B. Cannon have shed much light on the 
physiological workings of this control. Psychologically, it operates 
with a set of regulatory devices brought into play by the threat of 
injury. On the lowest level, this device is pain; on the affect level, 
fear and rage; and on the highest level, anticipatory thought. These 
devices in turn evoke the behavior patterns of riddance, flight, 
combat, and the call for help, designed to end or forestall the 
emergency. If emergency control is permitted to function as usual. 


ETIOLOGY AND PATHOLOGY 


47 


the individual has no chance in combat. 

Therefore, to become combat-proof, the soldier must learn how 
to shut off completely this control and respond to danger no longer 
as a sensitive man, but as a technician of war. Lack or failure of 
this adaptation exposes the emergency system to excessive activity 
and throws it out of order. In my opinion, this state of dys-control 
is the first step in the development of all war neuroses. Subsequently, 
the disturbance spreads to other systems or deranges the entire per¬ 
sonality. 

From this point of view the war cases may be classified as incipi¬ 
ent, acute, and chronic dys-control, reactive depression and schizo¬ 
phrenic episode. 

Incipient dys-control was studied by Armstrong in flyers and 
termed “aero-neurosis.” Acute dys-control may be subdivided into 
discharging, symbolic, inbound, and reactivating types. The first 
includes anxiety and rage attacks and states, the second the hysterical 
conditions, the third the psychosomatic disorders, and the fourth 
the revivals of the morbid pre-war personality patterns. Chronic 
dys-control is the traumatic neuroses proper which I suggested 
should be designated “traumatophobia.” It is characterized by the 
dramatization of a “trauma,” the dread of its recurrence, i.e.^ dread 
of combat and later of life, inhibition of repair, craving for com¬ 
pensation, etc. The reactive depressions and schizophrenic episodes 
are outside our present interest. 

A few words about the treatment of acute dys-control. In the 
last war “hypno-catharsis” or “narco-analysis” was employed to revive 
repressed war memories and discharge the “strangulated” affects. 
The results were discouraging. The soldiers relapsed as soon as they 
reached the front. Obviously, emotional purge cannot give more 
than temporary relief. In my opinion, the first task of treatment 
is to de-sensitize the soldier to his horrifying war memories by 
stripping these memories of their power to perturb him over and 
again, and instead turn them into a source of repeated pride and 
satisfaction. During this procedure the over-active affect systems 
of emergency control must be calmed down by appropriate medica¬ 
tion. When the symptoms, including the terror dreams, disappear 
and the soldier's initiative is restored, he must be retrained and 
taught the proper psychological technique of behavior in combat. 

If treated immediately, the incipient and acute cases may be 
returned to combat duty. But once the condition becomes chronic 
the man is lost for military service and unless readjusted soon to a 


48 


TRAUMATIC WAR NEUROSES 


civilian occupation he may become incurable. 

For a long time the merchant seamen were the forgotten heroes 
of this war. It is gratifying to see that under the able leadership 
of Dr. Blain such a splendid organization has been dedicated to 
their welfare. 

Chairman Bond: Dr. Deutsch! 

• Dr. Felix Deutsch: I want only to stress a few points of prac¬ 
tical importance. We saw here three cases presented, one the 
amnesia type, and as we looked at that case carefully, we could see 
his pre-traumatic personality. He talked with closed eyes today, 
in a detached way, showing his tendency to amnesia. 

The second I would call the worrying type, with anxiety, and 
the third was the type who told all that he experienced to bring 
back to reality, to impress us with details which he had observed 
in this great danger, in which his whole interest could only be 
centered to be safe. When I looked at this case, I recalled the 
experience which we had after the Cocoanut Grove disaster. There 
we had a real example of a trauma which was inflicted on indi¬ 
viduals by their pride. We saw the same kinds of reaction which 
were described here. One reacted with an amnesia and couldn’t 
remember anything that had happened during the fire. The other 
brought a complete, detailed description, how he saw the fire coming 
and how he tried to save his neighbor and what the neighbor did, 
and when we checked up these stories, we found they were mostly 
invented. They were the reaction of the individual who by all his 
anxiety in a reality experience showed today his defense mechanism 
in protecting himself against anxiety. Others do this by amnesia 
and still others by becoming the worrying type. 

We have a practical purpose here, and it is how to treat these 
patients. Our experience in Boston in civilian war neurosis started 
months ago, showed us as soon as we lose track'of the goal which we 
wanted to reach, we are lost. This goal can only be to bring back 
the patient to the condition in which he was before he had this 
traumatic experience. If we go further, we find we are lost, because 
we treat then a heroic neurosis. The technic has to be to know the 
pre-traumatic personality, to go then only in that direction; that 
is, to treat him, this part of his personality, an elective part of the 
personality, which was shaken in this moment or in the trauma, 
and then to be satisfied that we brought him back in this condition 
in which he was. We would be unable to continue our treatment 


ETIOLOGY AND PATHOLOGY 


49 


to the end because of lack of psychiatrists. Because of lack of a big 
staff, we are now burdened with cases in which we cannot finish 
the treatment because there are infantile neuroses which you can 
stir up in any treatment, and they have been stirred up and we 
cannot leave the patient alone any more. Therefore, the goal has 
to be to treat this part of the personality which was shaken through 
the trauma and then to be satisfied. 

Chairman Bond: Is there further discussion? 

Dr. Blain has suggested that possibly there would be some case 
• in point from one of the Marine Hospitals. 

Dr. Vestermark! 

Dr. S. D. Vestermark: Mr. Chairman, in complement to these 
cases presented by Dr. Blain, I would like to recite the experience 
of a 17-year-old leading gunner in the Navy. This individual came 
into the hospital, was sent to us after having been picked up by 
the immigration authorities. He was sent in because he couldn't 
be aroused. He was sleeping. I was called to see him in consultation. 
He was still sleeping. So we let him sleep without disturbing him, 
and when he got up, he told us his story. It was simply one of 
fatigue, and he related some most unusual experiences. 

He had been going to sea for two years. Off the coast of Iceland, 
the ship was bombed and he was in the water for two weeks, came 
through that experience without ^ny handicaps or any difficulties. 
He suffered no physical disability and no mental trauma whatso¬ 
ever. Six months later, while in the Mediterranean, he went through 
another bombing experience and spent about three weeks off the 
coast of North Africa near Tobruk. He then reshipped, came to 
this country, accumulated all of his savings, jumped his ship and 
spent about £500 in the course of a month’s time enjoying himself. 

Here was an individual who had gone through some of the 
most terrifying experiences. He showed us in his pre-traumatic or 
his pre-morbid personality many psychopathic traits and many psy¬ 
chopathic tendencies. In addition to that, he had other neuropathic 
traits, sleep walking, bed wetting, nail biting, temper tantrums. He 
would be, in all likelihood, that type of a personality that you 
would expect would crack or shatter or break under the impact of 
these terrifying experiences. 

It is my feeling that in dealing with these people that there is, 
as has been stated, a very definite type of underlying personality 


50 


TRAUMATIC WAR NEUROSES 



Structure. I think that is related to the arhount of time that we 
spend with these people; if we have adequate time and opportunity, 
we can find in most of these people some underlying pre-existing 
personality distortion or maladaptation that would lead us to believe 
that eventually this individual would be a potential candidate for 
some type of a breakdown under various stresses and strains. 

We feel that these people cannot be treated in the hospital. As 
Dr.'Blain has pointed out, they become dependent, attached. The 
depth of their neurotic disturbance becomes accentuated or exagger¬ 
ated, and it has been our experience that the quicker they can be 
gotten out of the hospital, perhaps some of them sent to a convales¬ 
cent home, as Dr. Blain has pointed out, they will recover much 
more quickly. 

As Dr. Rado has pointed out, we make no attempt to go back 
any farther than treating that part of the personality which has 
been disrupted or traumatized by the experience. Any attempt to 
probe or search for or seek any deeper into underlying unconscious 
motives or mechanisms will only serve to prolong, exaggerate and 
make worse the condition for which the individual has come to the 
hospital. So we devote ourselves—the reason is simply a matter of 
expediency—to getting the individual out because of the factor of 
time; secondly, because we do recognize that if we attempt to treat 
the underlying personality disturbance, we then induce a chronicity 
which makes for further difficulty. 

Chairman Bond: Is there a chance that we might hear from 
the Surgeon General of Norway, Dr. Karl Evang? 

Dr. Karl Evang: Mr. Chairman, speaking generally here of 
the etiology, I think there are a few fundamental points which 
ought to be stressed as far as the sailors on the merchant fleets are 
concerned. I am not a psychiatrist but I have seen a host of those 
cases. One thing, which is quite obvious, is that the sailors of the 
merchant fleet, even if they are fighting in the front line, are not 
protected by a military organization; and they are not strengthened 
by the fact that they are cooperating and fighting together with the 
same persons for a long time. 

The other thing which I should like to stress is the fundamental 
difference between the crew of a merchant ship and the crew of, 
for example, a destroyer or a cruiser, or the members of a military 



ETIOLOGY AND PATHOLOGY 


51 


force on land or in the air. The sailors have no means of fighting 
back. 

In the Norwegian Merchant Fleet, for example, it happened 
that we had to wait very long until we had protection for our ships, 
and our feeling was that even for the men who were not gunners 
themselves the very fact that they had a gun on board was an im¬ 
provement. It happened again and again, when you spoke to people 
being rescued from a raft or a lifeboat, members of a crew having 
been through indescribable hardships, when you asked them what 
they would do afterwards, they would say: “We are going back to 
sea, but this time couldn’t we first go through a gunner’s school so 
we would be able to fight back?’’ 

I think those two fundamental differences should also give us 
some guidance as to the prevention of war fatigue. 

Another thing I should like to stress from my own experience 
in Norway during the warfare is, again, something obvious. It is 
the surprising, the unexpected, the thing for which you have not 
prepared, which is bad. I happened to see much of the German 
bombing of civilians and defenseless towns of Norway, where the 
German planes could do what they liked, because there was no 
protection at all, no fighters, no anti-aircraft guns. I really saw 
very bad effects on the population in one single spot and that was 
in the bombing of the second day of the war in a small place called 
Elverum. I saw much worse bombing later, with more German 
planes and more terrible destruction, but the fact that the people 
of Norway had heard about these things and knew that they might 
happen, was a protection to them, not, as the Germans thought 
when they showed the terror film from Poland, that it would break 
down their resistance. 

I would like to close by mentioning the case, from Norway, of 
quite another type of mental disturbance as the result of war. It 
was a highly educated man, a civil servant, a very fine man at his 
best age, in good strength, in the north of the country, which was 
isolated from the south. He developed in one month a picture which 
resembled megalomania on a syphilitic basis, in spite of the fact 
that there was no syphilis at all. He had the feeling that the war 
threw upon him as an individual all the responsibilities, the military 
responsibilities and the civilian administration, everything. In a 
short while, he tried to organize the whole country. He died from his 
disease. 

Well, asked to speak here, I would like to thank you for the in- 


52 


TRAUMATIC WAR NEUROSES 


vitation and I would like to address my thanks on behalf of the 
Norwegian sailors first and foremost to Surgeon General Parran. I 
agree with those people who think that the sailors in this war are not 
only the forgotten men but the forgotten fighters. There are many 
things now indicating that we are through with that period, that we 
all see what we have done wrong by not understanding it before. 

Thank you! 

Chairman Bond: We are nearing the end of this part of the 
discussion. Is there anything that General Grant, of the Air Corps, 
would add? 

Dr. David N. W. Grant: Gentlemen, I am not a psychiatrist, 
but from the standpoint of the flyer, of course, I have been interested 
in this matter of neurosis and stress, or whatever term you desire, for 
many years. We, of course, have a selection for our people, not a 
very scientific classification, but I would like to classify our youth 
into five types. We feel that every man has a barrier as to what he 
can take, according to the work that he is to perform. Our selection 
system is based on that fact. 

We, for instance, (and I admit this is a very unscientific classi¬ 
fication) have the emotionally unfit individual, who is not a coward 
but he just hasn’t the nervous stability to take the stress and strain 
required in the flying game. He will last two or three missions and 
then he breaks and he is certainly not qualified for combat flying 
again. 

Then we have the constitutional type that we consider as a 
coward. He will take one mission or three missions, five missions. 
He never reaches the target and he is of no further use to us. 

We have the fair-weather type who always finds fault with various 
things. The ship is wrong, he doesn’t want to fly this ship, he wants 
to fly the other ship. He wants to be in pursuit, or if he is in pursuit, 
he wants to be in observation, and vice versa. 

Now those three types we try to throw out in our selection. 

We have two other types which we call the below average type 
and the average or better type. The below average type is a man who 
will “take” just a little less than the average individual, and if we 
get him and rest him, why he will come back and take it again. 

The average or better type is the man who is the average indi¬ 
vidual and he is the man with whom we have trouble, because he 
will never come to us and tell us when he is trouble. 



UTIOLOGY AND PATHOLOGY 


55 


Now, we have set up oiir main problem as selection and main¬ 
tenance. We also have a problem of classification. We don’t take 
any of these individuals and just put them in “hit and miss” classifi¬ 
cations of whether they are going into bombardment or pursuit. 
We try to classify them, whether they are fit for that particular type 
of work. Or if they go to altitude, they are also classified for altitude. 
We can’t take every man and shove him up above 30,000 feet. 

We also classify—though not to a very large extent as yet on 
account of the lack of instruments—on night vision, particularly the 
night fighters. We have followed the principle that we can take 
the below average or the average man and set a goal for him and pull 
him out at the end of that goal and rest him for a short period of 
time and then put him back. He will reach that goal again, and we 
can repeat it over and over again, and it works. 

I have just returned from Africa within the month, and I find 
men over there with fatigue conditions, but we can’t pull them out 
and rest them in between their combat hours. We have got men, 
entire crews, with 250 combat hours. One crew had 311 hours of 
combat. Now, we have set our goal at 120 hours of combat. Hon¬ 
estly, those crews are very much in need of relief on the front. I 
object very much to the use of the term “psychoneurosis” in con¬ 
nection with these people. 

I think with our people we have a tendency to confuse the war 
neuroses. This is not the case—if we can get these people back and 
give them proper treatment, we can salvage the majority and put 
them back. 

I might say this, that the higher the imagination,—which you all 
know,—the quicker they go out on you. We have much more 
trouble with our navigators than we have with the pilots or with 
our gunners. The navigator will go first with us and recover faster. 
The gunner has very little imagination or he certainly wouldn’t be 
back there in the rear. He will take a hell of a lot. When he goes, 
he is gone. 

We have to be very careful in pulling those people out. I think 
we are accomplishing a great deal. We are certainly making every 
effort. We have had very little difficulty in the actual loss of pilots. 
We have had a lot of strain and a lot of stress, but we are losing very 
few men for future use. 

I feel this very strongly—you have probably seen it in the papers 
just recently—because of the fact that we have now in every one of 
our hospitals a convalescent reconstruction program that covers every 


54 


TRAUMATIC WAR NEUROSES 


man in the hospital, in which, from the very minute he comes in 
and is able to do anything at all, he is placed on the system of exercise, 
of education, and other reconstructive ideas. For instance, at Jeffer¬ 
son Barracks, a man comes in for an appendectomy. The next day 
he starts his program and they make him exercise his hands. The 
next day he gets instruction in the ward about “booby traps” or 
what have you,—something to keep his interest up. We consider, 
you might say, this mental treatment to be just as important as the 
surgical or medical treatment. It is in effect in all of our hospitals 
today. Some of our hospitals have been slow in starting, but others 
have done a grand job with it. 

Chairman Bond: We are coming to the end of this third of the 
discussion just on time. I want to thank the distinguished members 
of the conference who participated and I now turn the session back 
to the presiding officer. 

(Surgeon General Parran resumed the chair.) 



I'VV 


s • 


\ 


TREATMENT 


«4 






4 "^ 


i 






TREATMENT 

« 

Chairman Parran: Thank you very much, Dr. Bondi 

These sections merge more or less one with the other. I realize 
that in a group such as this it it difficult to get the discussion down 
to the informal basis we should like to have, but I hope we shall 
continue to move in that direction. 

There are a number of guests from our allied nations whom we 
would have wished to call on this first section, but we hope they 
and everyone here will have something to say on one or another of 
these topics before the day is over. We shall proceed next to discuss 
the problem of treatment. Dr. Arthur Ruggles, President of the 
American Psychiatric Association, will please take the chair. 

(Dr. Ruggles assumed the chair.) 

Chairman Ruggles: I think in the matter of treatment, we 
should remember the words of Dr. Parran, that the maximum bene¬ 
fit in the shortest time should be our aim in this discussion. There 
are many refinements of treatment that we would like to consider 
as research problems, but we are all interested in the benefit to the 
man and the benefit to the service, and that means the greatest 
benefit in the shortest tinie. 

Dr. Blain has brought up a number of the things that they do in 
the matter of treatment, and I hope we can get time to dwell at 
reasonable length on some of those particular things. He spoke of 
occupational therapy. There are certain connotations in occupa¬ 
tional therapy applying to this particular group that we haven’t 
thought through, and also the question of the problem of the home 
against the hospital, the nurse in uniform and out. So that I think 
we should make this discussion very practical and keep in mind the 
experiences of those who have dealt with these particular individuals. 

The first speaker on this subject, to open the discussion, is Dr. 
Stephen Sherman. Dr. ShermanI 

Dr. Stephen Sherman: Thank you, Dr. Rugglesl 

57 



58 


TRAUMATIC WAR NEUROSES 


The treatment of the merchant seamen’s war neurosis, idealistic- 
ally speaking, should begin with the period immediately following 
the traumatic episode itself. Everything that happens to the seaman 
from the time that he enters the lifeboat bearing him away from the 
scene of the disaster may be said to be therapeutic or non-therapeu- 
tic to a high degree; the attitude of the crew as a group to^vard what 
they have been through, toward such powerful etiologic agents as 
panic, loss of shipmates, sights of unusual horror, or screams of dying 
companions, and so on; more particularly the attitude of superior 
officers toward the total war experience, which attitude weighs heavily 
in the mind of the average seaman; in other words, all those factors, 
subtle and overt, which have to do with the presence or absence of 
war morale, both individual and group. By and large, the tone of 
the merchant seaman’s morale suffers from a dearth of group feeling. 
That extra something which the army private has by way of his 
regular camp training and his identification with the Army, country, 
and the national cause, the seaman has only when he has been able 
to supply it from resources within himself. A program of psycho¬ 
logical first aid, to function directly from the time that the seaman 
becomes a survivor, could well be instituted for the Merchant 
Marine. 

In this it would be the duty of one member of the surviving crew 
to assume leadership and to regard himself as responsible for group 
morale until safety was reached. Muscular activity, as a means of 
releasing tension from pent up feeling, could well be encouraged. 
The men should be stirred to arouse and vent their anger over what 
they have been through, so that the foundation of repressed com¬ 
plexes through frustration could not be laid. It is possible that 
adequate psychological handling of the period directly following the 
catastrophe would fragment and disperse many of these traumatic 
war neuroses in the formative stage. But our experience in this 
realm is nil; we can only speculate and plan for the future and must 
pass on to a consideration of what we are actually doing for these 
cases. 

The aim of the therapeutic, scheme to meet the needs of these 
war neuroses cases is to catch the psychically disturbed seaman as soon 
as possible after he reaches shore. Where it can be arranged, a medi¬ 
cal officer, together with a social worker, meets the incoming ship 
bearing a load of survivors. Signs of nervousness and mental distress 
are noted, and the potenially ill seaman is informed of the existence 
of the available rest homes, or is referred to one of the seamen’s 




TREATMENT 


59 


clubs where he may further contact a physician if he so wishes. The 
effort is made to establish in the mind of the homecoming seaman 
that he is not alone, that he will receive the same regard and care as 
a member of the fighting forces, that his country is aware of his 
services and is eager to provide for his needs whether in sickness or 
in health. This note has been made to permeate the rest homes 
treating the cases of actual neurosis. Cases for treatment at the rest 
homes are selected with care. Very sick cases, those with active psy¬ 
chosis or developing states of acute mental disease, are referred to 
the psychopathic wards of the marine hospitals in each port. The rest 
homes are reserved primarily for the treatment of the fresh cases of 
traumatic war neurosis. It is believed that when a case is caught 
early there is excellent chance of forestalling the development of a 
severe chronic neurosis, and that the earlier the therapeutic inter¬ 
ference the better. To quote a division psychiatrist of the A.E.F. in 
1918, the treatment of acute neurosis is almost as urgent as that of 
acute abdomen. 

The seaman comes to the convalescent home with various mis¬ 
givings. He fears very often a sumptuous environment with over¬ 
tones of patronage before which he will feel compelled to adopt a 
cringing attitude. He finds instead something extremely simple, 
though nonetheless carefully worked out; a social atmosphere of 
comfort with a slightly Spartan touch, informal to a fault, hospitable 
but not unduly solicitous, guided by certain rules and regulations 
which are not all-embracing, and presided over by a cheerful, under¬ 
standing head nurse who steers a delicate course between firmness 
and sympathy. 

In the psychiatric base hospitals in France in 1918, it was observed 
that in certain wards the men felt they could not hold on to a tic or 
a tremor because it was against the grain of the ward’s morale. A 
similar kind of morale is labored after in our rest homes. The men 
are given to feel through the house atmosphere that it is the custom¬ 
ary thing for improvement to take place. All the adjuncts to this 
fundamental note fall in line; the way in which the affairs of the 
home are conducted generally, the recreation activities, the enter¬ 
tainments, the special pursuits provided for individual cases. An 
important ingredient in the whole supportive regime is the friendly 
interest of neighbors in the community who provide dances, sports 
events, and dinners for the men. These neighbors are chosen care¬ 
fully with an eye to their tact and acumen in the handling of personal 
relationships. 








60 


TRAUMATIC WAR NEUROSES 


With the morale of the total supportive regime as a base, treat¬ 
ment from there out is less complicated. No mention is made at 
any point of psychiatry, nor is psychiatric verbiage permitted among 
the staff. The seaman is never allowed to feel that he has become 
the victim of a mental illness, but is constantly led to feel that his 
symptoms are not signs of sickness but of normal fear. The approach 
to his war experience and his anxiety problem is this: that of course 
he has been afraid, that there would have been something wrong with 
him if he had not been afraid, that it is merely a question of whether 
he is to be the boss of his fear or vice versa. The simple term “war 
nerves” is used to cover the varied symptomatology presented, which, 
as in the case of the indeterminate label “N.C.A.” employed in the 
Army in the last war, leaves little for the patient to cling to as a 
stigma. The house staff as a group is oriented to encourage in the 
men the development of aggressive spirit, to inculcate the feeling 
that by pulling one’s self up by one’s own bootstraps one can do a 
great deal. At all times the supportive regime is left lax enough to 
make room in each case for individual initiatives. The psychiatrist 
is not designated as such but is known simply as a doctor; he starts 
out as a physician and only winds up as a psychiatrist. 

To come to treatment of individual cases, what do we do? Going 
on the theoretic assumption that the acute traumatic war neurosis 
is a surface phenomenon which has not yet struck deep into psychic 
strata, our aim has been to quiet the underlying neurosis if it is there, 
but to treat the acute neurosis. It is astonishing to find how a 
case responds to the immediate impact of the total supportive regime. 

The quiet and comfort of the spacious country scene, isolated 
from civilian pursuits; clean linen; rest and good food; regular hot 
drinks and eggnoggs at special hours—all have their combined tonic 
and sedative effect. Many of the men have come from several weeks 
of loafing around the dock district; many have accumulated the 
dregs of an alcoholic debauch. In the majority these experiences 
have not helped the neurosis. The outstanding symptoms—severe 
insomnia, diffuse anxiety, tremors and startle reactions, autonomic 
disturbances of all sorts—show an almost immediate lessening of in¬ 
tensity. The treatment of the acute anxiety state is a problem in 
itself which time does not allow of proper consideration here. Suf¬ 
fice it to say that in it medical and psychiatric treatment are com¬ 
bined, and that goal is to effect a breaking through into a new phase 
in which the patient is therapeutically labile. Certain cases are 
candidates for special attention in this regard. 


TREATMENT 


61 


Mention has already been made of the seaman’s particular char¬ 
acter problem, his adjustment to the group and to group feeling. 
To use Dr. Glover’s construct from the Bible, that in this weakness 
there may be a lot of strength, it was presumed that the seaman 
would respond to an approach along the lines of this very deficiency 
in his make-up; namely, that he would accept hospitably some form 

of group therapy as opposed to individual. This supposition was 
correct. 

During the opening weeks at the Oyster Bay home. Dr. Blain 
undertook the task of giving the men group talks on topics germane 
to their condition; war nerves, the importance of rest, sleep, work 
and play; the use and abuse of alcohol; the role of feelings in ner¬ 
vousness, and so on. These talks were cordially received and have 
been continued by the incumbent physician. It was found that the 
men could assimilate in a group lecture certain ideas which were 
painful and unacceptable in private. The main thread running 
through all of the talks has been the invigoration of self-confidence 
through a working knowledge of the body systems, so that one may be 
aware of the physiologic resources at hand in time of danger, the 
systemic defenses upon which the torpedoed seaman may count to 
bolster his morale. Discussion of psychic disturbances was kept 
simple and elementary, the principal effort being toward showing 
the importance of normal fear as a defense and safety measure, 
giving the seaman to feel that many of his symptoms derive rather 
from an excess of certain good qualities than any imagined defect 
of personality. This was the practice with the armed forces in 1918 
and it was highly successful. 

To come to individual therapy, each seaman receives upon entry 
into the home a preliminary interview with the physician which 
serves to orient the latter to the case and establishes the basis for 
further work. It may not be advisable to elicit the full history of the 
traumatic episode at the first meeting. Procedure following the first 
contact with the patient varies widely. In all individual therapy 
with these cases, the physician is schooled not to ask but to listen. 
The patient himself is allowed to determine the depth of the treat¬ 
ment. There has been a strict avoidance of the tendency to go in 
and plow up the wounded psyche. Patients have shown varying 
degrees of the need for emotional catharsis. In many it has been 
deemed wise to let the protective amnesia alone; it serves a healing 
purpose. When the patient himself unlocks the amnesia and lays 
bare the content of the traumatic episode, effort is directed toward 



62 


TRAUMATIC WAR NEUROSES 


establishing in the patient’s mind, in accordance with Kardiner’s 
formulation, a connection between symptom, trauma, and present 
tendencies to withdraw from the world at large. Here are a few 
thumbnail sketches showing the diversity of response to therapeutic 
approach: 

A tall, gangly Texas broncho-buster of 25, only a few years at sea, 
went through three equally severe torpedo disasters in five months. 
He noticed no symptoms until after the third experience, when he 
realized that he was nervous, shaky, irritable, and considerably 
speeded up. When he came to the home, he presented a mild manic 
picture, gave out that $200 had been stolen from him, and made 
many excessive demands. In four weeks this man underwent a 
noticeable personality change. He quieted down, lost his symptoms, 
became very friendly and devoted. He returned to sea and when last 
heard from was doing well. Therapy was confined to group talks. 

Severe cardiac disturbances defined a distressing autonomic con¬ 
dition in a 35-year-old Swedish man who showed an extremely rigid, 
suspicious personality. Ectopic beats, giddiness, and heart conscious¬ 
ness had confirmed in his mind that he had a serious heart ailment. 
Insomnia, loss of appetite, and general agitation leading to crying 
spells rounded out the picture. He had been in no actual torpedo- 
ings but for one and a half years was under constant strain of 
expectancy of attack, having seen bombings and submarines at a 
distance. The symptom picture began with dizziness on the last trip 
out, which was entirely uneventful. This man was untouched by 
either individual or group therapy, but showed a complete right¬ 
about-face when a hunting trip into the nearby hills was arranged 
for him, a reminder of boyhood days. He brightened up, showed 
less hypochondriacal concern for his heart action, improved in 
appetite and sleep, and two weeks later left to go back to sea. The 
exact degree of improvement was difficult to gauge. 

Individual catharsis seemed to be the most helpful factor in the 
case of one man who had been through two severe torpedoings, the 
second leaving him with a form of bronchitic asthma. He attributed 
this to a new kind of torpedo exhaling sulphuric gas. But his 
dyspnea was not adequately explained and was worst at night when 
he would wake and scream out. Nightmares of being sucked down 
with a raft and chased by devil fish were distressing. Diffuse anxiety, 
buzzing and humming in the ears, and sensomotor disturbances were 
present. Claustrophobia was marked and was attributed by the 
patient to having been locked in the boiler room during one of the 



treatment 


63 


torpedoings. Improvement, which was gradual, was complicated in 
the end by alcoholism. ' This man showed extreme conscientiousness 
about going back to sea and looked upon himself as a deserter for 
not returning at once. 

An exaggerated sensomotor picture was presented by a 30-year- 
old deckman who was first thought to be a paranoid praecox case. 
On sudden noise he jumped high into the air, often knocking over 
furniture. T here were terrifying repetitive dreams of the original 
catastrophe, which had been unusually severe. He was blown several 
feet off the deck out of a sound sleep and thought he was dropping 
down the stack into the boiler room. Scalding by steam was added. 
The trauma lit up old paranoid formulations. Diffuse anxiety was 
marked, with vagotonic disturbances. Auditory and visual halluci¬ 
nations with queer psychosomatic experiences and persecutory 
delusions followed. Individual therapy alone would touch him and 
he was seen three times per week. He developed a strong trans¬ 
ference to the house staff and improved to_the point where he wished 
to try it on the outside. On leaving the home he became frightened 
and put himself in the detention ward at Ellis Island. He has since 
been released but is still quite ill and remains a therapeutic 
challenge. 

N A 42-year-old Philippine cook and messman was knocked flat 
under a table by the torpedo explosion, which was his first. After 
some weeks,he suddenly noticed that he was so weak he could not 
lift a bucket of water, that he jumped at noises and felt someone 
behind him, and that he had cramps in the stomach. He had dreams 
in which he stabbed a friend who had been dead 15 years, and others 
in which his ship‘capsized upon him. There was hysterical deafness. 
A cheerful, jolly fellow, he played the guitar and smiled all day 
long. He looked optimistically upon his condition and felt he would 
soon be well. He returned to sea after two weeks, greatly improved. 
Two therapeutic interviews were considered sufficient in his case. 
Past history showed unusual stability. 

A new and recent addition to the therapeutic armamentarium 
has been the use of semantic group discussions on a smaller scale. 
Selected groups of five or six are brought into the physician’s study 
for a talk, and an informal seminar atmosphere is encouraged. A 
topic such as fear, for instance, is chosen and its semantic possibilities 
exploited. Each man is asked to contribute his own definition of the 
theme word, and the individual offerings, generally striking in their 
discrepancies, are utilized as points of departure for discussion. The 


64 


TRAUMATIC WAR NEUROSES 


talk is finally led back to a central point; real fear vs. irrational fear, 
and the ways in which a word or concept can be used by the psyche 
for good or ill. In this informal atmosphere the men tend to unfold 
eagerly, and the therapist is hard put to it to function adequately 
as a referee. This therapeutic approach combines the advantages 
of catharsis with a didactic element. The whole symptom picture 
can also be attacked through this channel. At a recent seminar, 
each of the five present were asked to say what came to mind with 
the word “symptom.” No. 1 said, “Jitters, unconscious fears.” No. 
2 said, “Afraid sit down at table, shaking.” No 3 said, “Sensitive. 
Be scared of a thing supernatural.” No. 4 said, “Noises.” No. 5 
said, “Shortness of breath. They gave us such a run-around; the ash 
cans and the feeding in the canteen.” The mixed physiologic and 
psychologic symptoms mentioned gave excellent starting points for 
talk. 

It is not right to leave the subject of treatment without mention 
of re-educational methods. Occupational therapy, the strengthening 
of psyche-soma through manipulative activity, was used to supreme 
advantage at Base Hospital No. 117 in the last war. The value of 
work, the physiologic and psychologic features that result from effort 
to overcome resistance, certainly cannot be overestimated. It is the 
conviction of the medical staff that it is important to teach the men 
that work in itself is curative, promotes sleep and relieves tension. To 
date, the problem of the utilization of work therapy in our rest homes 
has not been properly solved. Part of the difficulty lies with the 
seaman himself, who regards all the time spent on shore as dedicated 
to inactivity on the physical side. Hence an educational task lies 
ahead in gaining his interest and cooperation. Some of the seamen 
do expert drawing and sketching, and it is possible that this can be 
used therapeutically to ventilate specific traumatic experiences, as 
was done at La Eauche in 1918 with Army cases. Where a seaman 
is too sick to be returned to sea duty, measures are taken to interest 
him in another trade while he is at the home. The Oyster Bay Avia¬ 
tion Defense Training School has kindly offered its services to our 
men for courses in blueprinting and aviation mechanics. The men 
can step from these courses to excellent positions in the aviation 
defense plants and elsewhere. 

Regarding the cases of chronic neurosis, it has been the feeling 
of the medical staff that it is justifiable to spend the major portion 
of available time with the cases that show the best results, the acute 
cases. That does not mean that the chronic cases go neglected, but 


Treatment 


65 


they are not in the first line of therapeutic fire. Much time goes to 
them nonetheless by reason of their exhausting demands, and it is 
fortunate that they are instructive and reward the efforts expended. 
It is the hope of the medical staff that treatment of the acute cases 
will lessen the need for treatment of chronic cases by preventing 
their growth. 

The handling of cases at discharge is eased by the fact that the 
seaman is generally only too eager to get back to sea if he can, and 
conceives of the return itself as therapy. In this he rather differs 
from the soldier at the front. In addition, he needs to get back to 
sea in order to make money. The transition from the rest home 
back to sea is aided and abetted where necessary by the able and 
generous assistance of the social service department, whose experi¬ 
ences in contacting these men in their passage through the city in 
itself constitutes a chapter of medicine. 

One final word regarding therapeutic aims. The treatment pro¬ 
gram has been organized by Dr. Blain with a consistent goal at all 
times in view, to give the seaman who comes to the rest center some¬ 
thing that he can take away with him and use as a permanent 
acquisition. What is taught the men when they are sick is the same 
kind of thing that would be taught them when they are well. If 
a man walks into something that he does not know anything about, 
he is twice as afraid as if he were psychologically prepared for it. 
When he has something to grasp hold of, he is stronger. It is thus 
with the seaman who returns to his fighting front, the high seas. We 
want the patient not only to feel like getting back to work, but to 
take something with him as well. 

Chairman Ruggles: In the brief section on pathology and 
etiology, it came out several times there was a possiblity of divergent 
symptoms; that, of course, makes it possible there are divergent’ 
etiologies. And in seeing one at least of these patients here, it cer¬ 
tainly seemed as if there might be a neurological complication. 

Dr. Sherman has given us a very excellent presentation. Some of 
his cases were exposed to rather severe trauma. That brings to mind 
the possibility that we may have swung a bit far away from the con¬ 
ception of shell shock at the beginning of World War I, and that 
we may be seeing in some of these severe traumatic situations cases 
that have organic damage but also with some functional symptoms. 
I hope in the discussion of treatment Dr. Blain and his associates 
will speak of the question of neurological complications. We would 


66 


TRAUMATIC WAR NEUROSES 


like very much to hear from one of our distinguished guests from 
Canada, Brigadier Chisholm. We hope he will say something on 
treatment, especially in view of his experiences with men returned 
from battle fronts. 

Dr. G. B. Chisholm: Dr. Ruggles, personally I thank you 
most heartily and sincerely for your invitation, and also on the part 
of my colleagues of the Canadian Navy and Air Force, to be with 
you and learn something here. There is one matter that I think 
should be given a little more consideration than it has yet received. 
It has been referred to. It is found in all fields of etiology and 
treatment and prevention. One goes back to the early days of the 
last war in the years before shell shock was noticed; one found that 
the thing that men could not stand was futility, frustration. The 
thing that was most difficult and broke most men down was sitting 
down under shell fire for month after month, and even year after 
year, in the early years of the war, at a time when the enemy had all 
the preponderance of fire power, artillery, airplanes, machine guns 
and everything else. Those very difficult times produced large num¬ 
bers of casualties. Frustration in the Merchant Marine, the feeling 
of futility, being hounded across the ocean by a pack of German sub¬ 
marines without being able to do anything whatever about it, is 
emotionally very trying also. 

We are finding now in the Canadian Air Force in England, which 
is fighting, that we are having very little breakdown at all, whereas 
in the Canadian Army in England, which has been suffering now for 
three years from the futility of inaction, we are having large numbers 
of breakdowns. The men are having no possibility of expression of 
their hates and their aggressive feelings. 

It would be very interesting to know to what extent there may 
be any difference between the incidences of breakdown in freighters 
which on the one hand are completely unarmed and on the other 
in those which may carry airplanes or guns. It may be supposed that 
these men could associate themselves, gain some feeling of identity 
with the crews of the guns or the crews of the planes, which, as you 
all know, in some cases are carried on catapults and are prepared to 
be launched whenever necessary. It may be it would be worth 
finding out. I don’t know whether anyone here, sir, has any infor¬ 
mation on that point. But it may be that the arming of ships will 
have a very useful effect on the sailors themselves. 

During the early years of the last war, I was impressed by the 


TREATMENT 


67 


guilt feelings found in men who could not express their aggressions, 
sitting down under shell fire, piling up hates for year after year, with 
no place to go, which frequently made men turn on their superiors. 
They could do nothing about their hate of the enemy and they 
frequently became very critical and very aggressive toward their 
non-commissioned officers and officers. It might be that useful 
treatment could be found by helping these sailors to express their 
aggressions more freely. It might be that movies, for instance, taken 
of airplane raids on German U-boat harbors might be very useful 
indeed. If these sailors could feel themselves identified with some¬ 
body who is taking it out a little on the U-boats, they might be able 
to use up a great deal of their pressures. Distribution of souvenirs 
from destroyed U-boats might also be helpful. 

I would like very much to know if anyone has any figures on the 
incidence of frustration reactions in various kinds of ships, armed 
or unarmed. 

Chairman Ruggles: Thank you, Brigadier Chisholm. 

I hope the following speakers will keep in mind Brigadier 
Chisholm’s question as to the incidence of war nerves on those 
unarmed and armed ships. I am sure we all want to hear again 
from Lieutenant Rome of his experiences in the Southwest Pacific; 
and probably more than any of the rest of us, he has seen cases early 
in their career and that have been emphasized in the matter of treat¬ 
ment. Lieutenant Rome! 

Dr. Howard Rome: Dr. Sherman has outlined a plan similar 
to the one which we had adopted at an advanced base hospital in 
the Southwest Pacific. Our cases were made up of our Marines 
serving as ground troops and a smaller number of Navy personnel in 
service on ships in the area. Apropos what Brigadier Chisholm had 
to say, the men who were constantly anticipating raids or action 
and yet, who after a period of eighteen to twenty months had 
never had action, had a much higher incidence of traumatic neuroses 
than did the men who were in actual combat. 

The therapy we employed combined expediency with two other 
factors. One, of the use of sedatives to diminish their hyper irritable 
response to environmental stimuli and, second, the retraining in 
stable action relationships by planned direction. 

Sedation was most important because it blanked out the noise 


68 


TRAUMATIC WAR NEUROSES 


and action stimuli in the environment which could not otherwise be 
controlled. 

Group psychotherapy has to be lived in constantly, not merely 
exposed to intermittently. Accordingly meals, recreation, group 
sessions and rest periods were planned for. As Dr. Sherman men¬ 
tioned, assurance and solicitude were the supporting elements in the 
background. Since, in all military situations, security is wholly 
dependent upon collective action, the earlier in rehabilitation that 
the patient becomes aware of this and affiliates himself the sooner is 
he freed from his symptoms. In a group, security is gained by a 
mutual pooling of individual insecurities. The group becomes the 
reservoir from which all members are eligible to draw the additional 
security necessary to fulfill their personal demands. 

Apropos what General Grant said, the physiological consequences 
of fatigue often assumed psychological significance and we felt that 
these patients were in a little different category. Help for these 
people lay mainly along the lines of aiding the normal recuperative 

function of rest. 

The idea of not going too deeply into the psychopathological 
background we found extremely important. Not infrequently in 
our early enthusiastic attempts to bring about cures, we stirred up 
hornets’ nests. Group psychotherapy in a large measure precludes 
this. 

The plan of therapy as outlined by Dr. Sherman has my enthusi¬ 
astic endorsement. 

Chairman Ruggles: Dr. Daniels, may we hear from you on 
your treatment experiences? 

Dr. George E. Daniels: Dr. Ruggles, I am very sorry that the 
treatment of traumatic neuroses is something that I have had little 
medical experience in. I did have the privilege and opportunity, 
however, of seeing some of the men at one of the rest camps described. 
I was very much impressed with one thing; the readiness of these 
men to talk of their experiences. Now, it seems to me that this is 
perhaps one of the most crucial points in the whole treatment of 
this group of disorders. 

It has already been stressed that in the present program for treat¬ 
ment of patients, there is made an effort as far as possible to follow 
along the normal sequence and let the patient take somewhat the 
lead in indicating how deeply the situation should be gone into, 


TREATMENT 


69 


This, it seems to me, is extremely important. 

Dr. Blain and some of the others have stressed the effort, where 
it is possible, to glide over the disturbing experiences. I think as 
time goes on, however, it will be more and more necessary to pick 
out the patients which will need some further psychotherapy than 
what at the present time is being given, because of the possibility 
of later breakdown. 

Now, to go back to this matter of the ability of the men to talk 
about their experiences—and this was simply at the table during mess. 
Fortunately, in the profession of seamen we have the tradition of 
being able and glad to spin yarns about adventures. This, I think 
is a very important tradition, because it gives an opportunity for 
therapeutic exploitation. As the men come back from these experi¬ 
ences, when they gather in groups to discuss their adventures or can 
be called upon from time to time to speak over the radio or in other 
gatherings, we have a natural type of psychotherapy operating. 

What I was particularly interested in in the discussion of treat¬ 
ment, so far as presented by the professional staff, was the use of 
group therapy. This, I believe, will give a medium for therapy 
and a screening of cases which perhaps cannot be gotten in any other 
way. We have recently had occasion to go over some of the litera¬ 
ture on group psychotherapy in preparation for its use in the present 
emergency. I hope a report on this subject is coming out in the April 
number of psychosomatic medicine. 

Now, in this the types of experience fall into two main categories, 
the inspirational or repressive approach to group psychotherapy or 
treatment and the analytic approach. Schilder has emphasized the 
importance in group psychotherapy of allowing the patients to bring 
out their own experiences, and I was very glad to hear Dr. Sherman 
say that in his groups or the groups that have been established this 
is possible to accomplish. This will give them an opportunity to 
pick out the individuals that need further individual psychotherapy, 
while at the same time in this initial stage there is a catharsis, a 
diffusion and repetition of their experience in a therapeutic manner. 

Pratt and others that have had a great deal of experience in group 
therapy lay emphasis on the importance of having the star patients 
in a group go over material with new members. With men of the 
Merchant Marine, because of the heroic and constructive value of 
their exploits, a repetition is made more possible, whereas in some 
other types of painful experiences this might not be as possible. 

Something has been mentioned about the necessity for getting 


70 


TRAUMATIC WAR NEUROSES 


out aggression. Schilder, who had done more in the analytic 
approach to group psychotherapy than anybody else who has re¬ 
ported his experience, found that in a group very often the individual 
will bring out aggression toward the leader of the group, whereas he 
won’t toward the same individual in his consulting room. Certainly 
not only through the use of moving pictures, lectures and in other 
ways, can the group be used as a therapeutic medium to promote 
emotional catharsis, but also as a most important vehicle for the 
building up of the morale and the development of techniques for 
meeting combat which have been stressed as an important factor. I 
believe it would act by way of prevention to hear experiences as 
’adventures from shipmates for those who are going out or have 
come back and have not yet met with disasters. This would act as 
an important immunizing procedure for them. 

Chairman Ruggles: Thank you. Dr. Danielsl 

Perhaps Surgeon Commander Mussen might answer Brigadier 
Chisholm’s question. We would like to hear from him. 

Dr. R. W. Mussen: My interest in this matter of psychiatric 
casualties among merchant seamen was first stimulated by a very 
interesting talk which I had with Dr. Kubie several months ago. 
Before then, I had been more concerned with the physical well being 
of these men. 

As he stressed the results of the hazards of war on merchant sea¬ 
men, I was prompted to enquire whether he thought that this group . 
was in this respect different from seamen in fighting ships. He said 
at once that he thought that they were: that the whole psychological 
background of the merchant seaman was different, that they often 
had no homes or family, and that the risks which they ran in war¬ 
time were more continuous and hazardous than those borne by the 
average naval sailor. In addition, of course, there is much less 
glamour, and less organised care and entertainment, which is looked 
upon as the right of the fighting services in wartime. 

I think that there is a lot to be said for this argument, and it is 
a matter in which all of us who are connected with the naval services 
must take a large interest 

I should like to mention two points only. The first is the ques¬ 
tion of fatigue. I have seen large groups of survivors after several 
land actions, and have been impressed by the importance of fatigue 


treatment 


71 


in their general condition, and the necessity for adequate rest and 
sedation in many cases. 

I think that the less you mention the word ‘traumatic’ in connec¬ 
tion with the psychoneuroses of wartime the better, whether in the 
Merchant Service or in the Navy. It appears to me to be getting 
dangerously close to the term ‘shell shock’, as used in the last war in 
France. Someone has mentioned the occasional case of true corn- 
motional injury to the brain. This recalls an observation of Dr. 
Gordon Holmes at the British Shell Shock enquiry in 1920. He 
stated that a distinction which he had noticed between the case of 
true commotional injury on the one hand and the psychoneurotic 
on the other was that the individual with true injury was very much 
annoyed if he was put in with the so-called shell shock patients. 

Chairman Ruggles: Thank you very much! Dr. Words, would 
you speak on treatment and any experience you may have had with 
these commotional cases? 

Dr. S. Bernard Wortis: I have been seeing torpedoed seamen 
both at the Bellevue Psychiatric Hospital and at the United States 
Marine Hospital at Ellis Island. Most torpedoed seamen do very 
well, despite the severity of the stress of worry, anxiety and actual 
torpedoing. Most torpedoed seamen are anxious to get back to se^ 
and do so. Only a small proportion of torpedoed seamen require 
hospital and convalescent care. 

The number that come to hospitals with related head injuries, 
such as brain concussion, contusion or brain laceration, is small. 
Many of these have the usual symptoms of headache and dizziness 
which may be associated with other neurological signs. On the whole, 
one is impressed by the paucity of associated neurotic signs—as com¬ 
pared with individuals similarly injured in industry. This, I believe, 
is largely due to the patriotic feeling the seamen have that they are 
doing a dangerous but essential job. They are today socially accepted 
as heroes and this social blessing, plus their own conscious desires to 
help in the war effort, is partly responsible for the low incidence of 
neurotic casualties. We may well see an increase in neurotic symp¬ 
toms of these men when the war is over. Some few of the torpedoed 
seamen may be putting on a front of toughness—they may be 
malingering health to show what virile fellows they are. 

Several features strike me as important ones in the prevention 
of nervous casualties in torpedoed seamen. First and most impor- 


72 


TRAUMATIC WAR NEUROSES 


tant is the need for strong, respected and understanding leadership. 
The captain and the ^ship’s doctor are the most important people as 
regards the establishment of good morale or good stamina on board 
ship. If the men in command show no signs of fear or anxiety, the 
possibility of their developing in the seamen on their ship is much 
minimized. Anxiety and panic are contagious emotions. 

Furthermore, what may look to the civilian psychiatrist like severe 
mental illness following physical and psychological trauma, is less 
ominous in war conditions where the factor of fatigue plays a most 
important contributing role. Generally speaking, we may say that 
the prognosis for recovery in cases of “war nerves” is remarkably 
better than for nervous and mental illness incurred in civilian life. 
Many fatigue states are misdiagnosed psychoneurosis. 

When men know what they are fighting for, morale is high and 
neurotic casualties are low. It therefore would be wise to instruct 
our merchant seamen, just as is being done for our soldiers and 
sailors, what we are fighting for, and why. 

Thirdly, when men are tired following severe traumatic expo¬ 
sure, the military physician should be instructed to insure adequate 
sleep. The sooner this is done following the onset of neurotic symp¬ 
toms, the better the chance to rehabilitate the patient. 

Finally, it appears to me that the merchant marine, during the 
war, should be incorporated into a regularly recognized, uniformed 
government service. This would improve the stamina of the men, 
give them formal recognition, improve the spirit of cooperation and 
work, and result in fewer nervous and mental casualties. 

Dr. Lawrence S. Kubie: Dr. Ruggles, I have a few fragments of 
data that offer a partial answer to Brigadier Chisholm’s question. Our 
numbers were small, particularly after weeding out unsatisfactory 
cases, so that our statistics offer nothing more than a lead. We 
found that the only vessels in which there was an outstandingly high 
incidence of severe disturbances were the tankers. On the other 
hand, the severity of disturbances did not correlate with the position 
of the man in the ship, whether he was below decks or on deck, 
whether he was asleep or awake, or various other considerations to 
which significance has been ascribed in the literature. Although the 
impression lacked full statistical validation, everyone felt that arming 
the ships and the men made all the difference that one would antici¬ 
pate. Even a pistol, however ineffective, wrought a difference in the 
men’s sense of helplessness, and relieved the awful strain of waiting. 

Now I would add a word to the discussion of therapy. The point 


TREATMENT 


73 


I have in mind seems to me to have a significance which is both 
practical and scientific. 

Surgeon Commander Mussen has mentioned the importance of 
fatigue, sleep, and sedation. Sedation has also been mentioned by 
Dr. Rome. This is the point I would like to pick up. In the first 
place, the general relationship of sleep to the psychotherapeutic 
process is a problem which has never been adequately investigated. 
In sleep some individuals pendulate back to a storm center of emo¬ 
tional stress which then persists through the following day, whereas 
other individuals in their sleep achieve a state of relaxation and rest, 
so that they seem to start the next day with a slate which is cleared 
of the emotional storms of the preceding day. Indeed, this is one 
of the differences between the individual who gets sicker and sicker 
and the individual who stays well under stress: and we do not under¬ 
stand this difference because no one has studied it. Just as no one 
has studied the difference between the nightmare whose terror is 
over as you waken, and that whose terror persists. 

In our own experimental work it is becoming clear that in the 
process of falling asleep, and again in the process of waking from 
sleep, and also recurrently during the course of sleep itself whenever 
sleep lightens, a state of partial sleep occurs. We don’t know quite 
what to call this. It is a hypnoidal state, or a state of hypnagogic 
reverie. In this state the mind is busy trying to rid itself of the 
unresolved tensions and terrors of the preceding day. This is why 
during the process of drifting into sleep or while slowly awaking, the 
sailors are most likely to suffer from terrible nightmares. These 
dreams begin as an effort to find a happier ending to the horrors in 
which so many of their shipmates have perished; but the rising 
terror wakens them before they achieve that goal, so that they waken 
in a frenzy of unresolved somnambulistic panic. 

This leads to one obvious and practical suggestion, namely, that 
in planning any regime of treatment for these men, their sleep should 
be carefully controlled and supervised from the moment of their 
rescue, even before they begin to show any emotional distress. Since 
the passage between the waking state and the sleep state is their most 
vulnerable moment, they should be precipitated into sleep as swiftly 
as possible, by using the most rapidly acting sedatives that we have, 
such as seconal or pentothal. And since they should be maintained in 
profound sleep throughout the night, the quick-acting sedative 
should be combined with those which act more slowly and for a 
long period, such as the barbital group. And when the patients are 


74 


TRAUMATIC WAR NEUROSES 


to waken, they should be wakened rapidly and in such a way as to 
bring them back quickly into contact with reality, so that they don’t 
again pass through this half-waking, half-sleeping hypnoidal state in 
which they tend to relive and to reactivate the original panic. Every 
sailor that I have seen who has developed severe daytime panic states 
has gone through a prior period in which he established this pattern 
during a poorly handled sleep regime immediately after the 
catastrophe. 

Such a regime implies also that there should be close supervision 
of the men as they are falling asleep and as they are waking from 
sleep. In fact, it is best not to allow the men to waken by them¬ 
selves. They will waken too gradually. It is better to rouse them 
from a profound sleep into full activity. Furthermore, such a regime 
should be maintained for weeks after the experience, precisely as we 
give luminal or bromides to an individual who had had a head 
trauma, as a prophylactic against the later evolution of organic 
disturbances. 

In emphasizing the importance of sedation and an adequate 
supervision of the sleep regime in the prophylaxis and treatment of 
traumatic war neuroses, we should not overlook the correlative im¬ 
portance of making it possible for the patients to ventilate openly 
their pent up feelings and to relive and recapture forgotten details of 
what they have been through. Catharsis and the penetration of 
amnesic barriers are both poorly understood concepts and processes 
for which excessive claims are often made. We must guard ourselves 
against dogmatic statements about their value. We don’t know 
enough about either process. The unsolved questions which center 
about them go to the roots of the problem of all psychotherapy. We 
don’t know why it is that certain types of emotional discharge make 
an individual well, whereas other types of emotional display such as 
depressions or anxiety states are self-perpetuating disturbances. Sim¬ 
ilarly we don’t know why it is that the recovery of data which is 
lost to conscious memory causes a disappearance of symptoms in 
some cases, and in others cases seems to have no therapeutic action. 
These are problems which are in need of all the objective investiga¬ 
tion that we can give them; but about which we have no right to 
make dogmatic assertions at this time. 

Dr. a. a. Marsteller: It seems to me that in considering the 
subject of treatment the terminology is a most important con¬ 
sideration, certainly throughout our Navy. Throughout the Navy, 


treatment 


75 


to the average bluejacket, the diagnosis of a psychoneurosis is 
synonymous with a psychosis. Likewise, a neurosis. So that even 
if the patient eventually gets back to duty status, he feels that he is 
stigmatized. He feels that his shipmates and all know that he has 
been in what they call the “nut ward.” He is just unable to face 
the situation. So that I was very glad to hear “war nerves” used. I 
don’t know whether that is entirely satisfactory from a naval stand¬ 
point, because it still carries a certain implication with it. I would 
like to hear some more discussion about that. 

Chairman Ruggles: Colonel Halloran, will you say a word on 
that? 

Dr. Roy D. Halloran: I have been very much stimulated by 
the various discussions about the treatment of the neuroses and the 
various elements in which the neuroses occur because it seems to me' 
that the questions of etiology and treatment depend, to some extent, 
upon whether there is a difference between the effects of the elements 
in which these neuroses occur. If the effects of sea, air, and land 
fighting are different, then perhaps we should and may expect some 
different symptoms which require different treatment. There is one 
factor which I think we should consider very seriously and that is 
the factor which has been touched upon—selection. 

The Army differs very radically from the Navy and the Air Force 
and, of course, the Merchant Marine, in the fact that the men are 
not selected; that is, as a rule they do not usually come in voluntarily 
There is an element of selection, of course, at induction. Whether 
that voluntary element in other branches of the service will make a 
different picture as far as the risk is concerned—as far as precipitating 
factors which may result in real neuroses when the battle line is 
reached, or before,—depends upon whether a volunteer constitutional 
factor exists and how important it is. 

It has been said here today that there has been some question as 
to whether the constitutional factor is important. Now there are 
some experiences which have come out in some fairly recent confer¬ 
ences abroad, which indicate that along the present battle lines there 
are those who have what is known as good constitutions and those 
who have what is known as poor constitutions. In those having the 
good constitutions it has been found that by sedatives, and rest for 
twenty-four to forty-eight hours, plus adequate diet, about a third 


76 


TRAUMATIC WAR NEUROSES 


of these can be returned to duty. But they must be reached im* 
mediately. 

Military forces are equipped with certain sedatives so that the 
neurotics can be given some sedative promptly and put to sleep. It 
is found that in these good constitutions the condition improves, but 
in the poor constitution soldiers have to be removed backward to the 
larger centers and the element of recovery is not so great. I think 
that this experience seems to indicate that there is an argument for 
a difference in constitutional background which makes some in¬ 
dividuals more susceptible to war neuroses than others. 

It is true that in the Army, thus far, we have not been so much 
on the combat line as the merchant seamen and the Navy. Most of 
our difficulties have been in the training period. There is an element 
of protection in this processing, because before the front line is 
reached many of the susceptible are removed. 

Possibly you are aware that we have initiated a nation-wide 
development of replacement training center mental hygiene units, or 
consultation services as we usually call them. These are manned by 
a neuropsychiatrist, psychologist, and a psychiatric social worker and 
operate apart from the hospital, in close connection with the classi¬ 
fication section. The purpose of these units is to educate the unit 
commanders in the early recognition of mental disorders and to pro¬ 
vide early treatment and disposition. Some very beneficial results 
are accumulating and already the work of the hospital sections has 
been considerably relieved, since many may be retained in regular 
service rather than hospitalized. The neuropsychiatrist uses consider¬ 
able ingenuity in giving insight to the line officers, chaplains, provost 
marshals, and general medical groups so that early recognition may be 
effected. 

I may say that the neuropsychiatrists in charge of these units have 
been carefully selected and trained at previously established units 
so that they have some idea about the method of organizing these 
services. 

A school of military neuropsychiatry has been established at 
Lawson General Hospital, Atlanta, Georgia, under the directorship 
of Colonel William C. Porter. There a group of officers from all the 
service commands, the medical pools, and the Air Forces attend 
courses in monthly quotas. Discussions and lectures are held on 
clinical and administrative subjects and the new developments along 
mental hygiene lines are freely discussed. 

I feel very happy to be here and to represent the Surgeon General 


TREATMENT 


11 


of the United States Army today. He hoped to get here but was 
unable to do so. We appreciate that if we are to derive some benefit, 
we all must work together. We must all observe these and other 
experiences about which we are hearing this morning, compare 
notes, and work together in studying these situations from time to 
time so that we can take advantage of these investigations as they 
pertain to cause, prevention and treatment. 

Chairman Ruggles: Thank you. Colonel Halloranl 

I would like to say just this in Connection with what Colonel 
Halloran has said about pooling our ideas and swapping our experi¬ 
ences: The half-day session at the May meeting of the American 
Psychiatric Association will be given up to these problems of the 
neuroses in the Merchant Marine and also to the psychiatry in the 
Navy and in the Army. Perhaps I shouldn’t use the word “psychi¬ 
atry” in this connection, but those common problems of the central 
nervous system will be taken up and it will be a very excellent oppor¬ 
tunity for sharing our experience and of determining, following this 
conference, other methods of treatment. 

Dr. Kelman, may we hear from your experiences at the Marine 
Hospital? 

Dr. Harold Kelman: We in the marine hospitals have an ex¬ 
cellent opportunity to study the traumatic neuroses in civilian life 
as well as subsequent war hazards. 

In the past seven years I have been able to see a great number of 
these cases. This includes people of all nationalities, races, colors, 
creeds, people from all over the world, from all financial levels, 
through the depression and now into a period where there is oppor¬ 
tunity to work. I have been impressed with the fact that you can 
find exactly the same things following traumatic experiences in 
civilian life as in war. Over-emphasizing the special nature of the 
traumatic neurosis in war or civilian life as differentiated from neu¬ 
roses not subsequent to obvious trauma confuses rather than clarifies. 
In fact, I believe that trying to derive a general theory of the neuroses 
from a particular syndrome is reversing the process. 

In the Neuropsychiatric Service of the United States Marine 
Hospital at Stapleton, of those cases of traumatic neurosis in seamen 
seen in the last six months, that were sent to rest homes, there were 
four who were considered to have had an obvious previous psycho¬ 
neurosis. To me, their war trauma was just another incident. Then 


78 


TRAUMATIC WAR NEUROSES 


there were seven more whom I considered to have had a traumatic 
neurosis following bombing or torpedoing. Two of these had in 
addition what is known as “immersion foot.” 

We have treated torpedoed seamen in the early days before ships 
were convoyed or had their own guns. The symptom picture was 
the same then as now. I feel that absence of equipment and training 
for self-protection exaggerates the seamen’s feeling of helplessness. 
Any material or technique that favors a greater resourcefulness of 
these seamen while they are on the boat, anything that favors group 
cooperation and group participation, anything that enhances their 
importance on a job with the equipment to defend themselves, I 
think is of paramount importance. 

Fatigue is an important and outstanding symptom in the trau¬ 
matic neurosis but is only one of the symptoms of this disorder. 
Symptomatic treatment is adjuvant, while psychotherapy is basic 
therapy. Various combinations of sedation have been used. The 
fatigue factor is prominent in men coming off ships having gone 
through danger zones, among men in the defense plants who have 
worked very long hours, and in veterans of World War I. 

Some very interesting observations were made of fatigued patients. 
On admission they often say that they are so fatigued they cannot 
sleep. We use doses of phenobarbital up to grains one with tincture 
of belladonna minims ten, four times daily, and barbiturates at 
night. Sometimes, to break the vicious circle of over-fatigue and 
sleeplessness, we may use, intravenously, seven and one-half grains 
of sodium amytal and even up to fifteen grains of sodium amytal. 
Such doses should be used only by those experienced in the use of 
this medication, because very frequently one may get respiratory 
difficulties. I have found that once a fairly sound sleep is established, 
they go into an almost stuporous state. They may remain in this 
type of slumber for about seven or ten days and then natural sleep 
hnally supervenes. They are then put on graduated activities of all 
types. Balneotherapy is of considerable value. 

Our emphasis in this hospital is on the use of medication, diet, 
and physiotherapy and some psychotherapy. The ward atmosphere 
is conducive to the feeling that they have a right to their illness, that 
it is quite legitimate and that we expect improvement. This feeling 
is nurtured by the ward personnel and favored by the frequent de¬ 
parture of men who have recovered, back to their former occupation 
as seamen. We have also noted something that has been emphasized 
many times here, namely, that they are anxious to get back to sea. 


The point also has been made that we find many people who have 
adjusted in civilian life and yet in time of war have developed a 
traumatic neurosis. I think the term “adjustment” is a somewhat 
rigid term. If we would think in terms of a creative spontaneous 
form of life, with satisfaction, some happiness, and some sense of par¬ 
ticipation, we would have a much better criterion. There are many 
people who, from a social viewpoint, are well adjusted. They have 
good jobs, have been successful, are family men and active in their 
communities. Socially they are adjusted and yet they are really 
basically very frustrated individuals. It has been my impression, as 
has been pointed out by Dr. Kardiner, that the stammerers, the epilep¬ 
tics and those with severe autonomic disturbances would be the types 
of individuals who are prone to develop traumatic neuroses. They 
cannot stand the break-up of the defense systems caused by the 
trauma because of a rigidity of their character structure. The feel¬ 
ing of falling to pieces which we see in working with psychoneurotics 
whenever any kind of defense, minimal or maximal, is broken 
through, is, I believe, present in an exaggerated form with patients 
who develop a traumatic neurosis. Their lack of flexibility makes 
them more susceptible. 

Chairman Ruggles: Thank you. Dr. Kelman! 

The work at La Fauche in the first war was referred to by Dr. 
Sherman. Perhaps this war is so different from the last war, we can 
learn no lessons; but several speakers have intimated there were some 
common principles running through the whole situation. I remem¬ 
ber very well the work of Colonel Hurst of the British Army in the 
last war, who made use of the retention in the ward of star patients 
for the group therapist and for setting the atmosphere, which Dr. 
Blain has so well done at the rest homes, for the improvement of the 
patients. Dr. Roscoe Hall took part in the treatment at La Fauche. 

Dr. Roscoe Hall: Perhaps I might take advantage of General 
Parran’s invitation to talk about some earlier topics to which refer¬ 
ence has been made. It is well to hear so much stress laid on 
the immediate situation and not so much on the background. We 
still hear the word “predisposition” which, after all, we know very 
little about. 

I should remind you of two studies of predisposing factors in 
psychoneuroses that show how important is the point of view of the 
observer. In the lancet of 1918, Dr. Julian Wolfsohn reported such 


80 


TRAUMATIC WAR NEUROSES 


a Study of British soldiers at the Fourth London General Hospital. 
He found that more than 70% of them had a family history of 
neuropsychiatric determinants and that more than 72% of the 
patients had a history of neuropathic constitution. Dr. Sidney 
Schwab, Medical Director of Base Hospital No. 117 in the A.E.F., 
in a similar study found neuro-psychiatric determinants in family 
and personal history in some 30% of the patients. The difference 
of some 40% obviously was in the point of view of the two neuro¬ 
psychiatrists — unless one brings in nationality, which is absurd 
here. In other words, one has to look for what one wants to find 
or perhaps one won’t find it. 

Dr. Rado may remember that the other day at St. Elizabeth’s 
Hospital he saw a patient, a chief water tender, who was on tfie 
U.S.S. Hornet from the time it was commissioned until it was sunk. 
This man was 38 years old and had had eleven years’ service in the 
Navy and previously was a sergeant in the Marine Corps. For 
two months before the Hornet was sunk he was actively psychotic 
with a paranoid schizophrenic reaction — including the usual aud¬ 
itory hallucinations — c.s., s.o.b., etc., — but this psychosis did not 
interfere with the performance of his duties. On the day of the 
sinking he did an excellent job as a chief water tender and, as 
many of you know, that is not a sinecure. I happened to take him 
to a medical students’ clinic and one of the students asked him, 
‘!Did you hear these voices during the day of the battle?” The 
chief, who was a very laconic individual, said, “No. I was kinda 
busy then.” Later on, after his rescue and arrival at San Diego, he 
began drinking heavily and his psychotic reaction increased and a 
near-panic state ensued. He has now made a very good recovery. 

I think the point that Dr. Schwab made some time ago at one 
of the National Research Council Committee meetings is pertinent 
— that it is not entirely a matter of ruling out the neurotics from 
the armed services but also of ruling out the neurotics who are not 
going to be able to make a satisfactory service adjustment. Many 
neurotics make a much better adjustment in the armed forces than 
they ever did in civilian life. As someone said this morning, perhaps 
a number of men become merchant seaman because they are neurotic 
in the first place. Dr. Kubie also spoke of how much more comfort¬ 
able many merchant seamen were at sea than on land. I am certainly 
not advocating the employment of neurotic individuals as such, but 
I believe that we could well afford to pay attention to their assets 
as well as to their liabilities, 


treatment 


81 




I thought that the general program of therapy that Dr. Sherman 
outlined was excellent and much in keeping with the spirit and 
practice of Base Hospital No. 117. I believe that one of the most 
important factors is the personality of the entire staff. In the A.E.F. 
many of us Soon learned that time and care spent in the selection 
and training of top sergeants were far from wasted. 

I will conclude with a word about a belief that so many indi¬ 
viduals have found of comfort to them. That is pure, rank fatalism, 
and expressed in doughboy language it was the familiar “if a shell 
has your number on it, it will get you.” The chief water tender 
that I referred to spoke spontaneously of this belief. I may remind 
you that some of the finest soldiers in the history of the world 
were fatalists. As a specific example, the Mohammedans who gave 
the Crusaders many memories. The British have not forgotten Galli¬ 
poli. It seems to me that we, as psychiatrists, neglect a factor that 
therapeutically so many persons have found useful in times of 
stress and danger. 

Chairman Ruggles: We still have adequate time for the com¬ 
pletion of this discussion on this most important section on treat¬ 
ment. I would like to hear Dr. Overholser. 

Dr. Winfred Overholser: One or two thoughts have occurred 
to me in connection with the comparison between the problem of 
the enlisted men in the Navy, "and those in the Merchant Marine. 
One of them is a semantic problem, perhaps. It has developed in the 
Navy and the Army that the term psychoneurosis is essentially 
synonymous with discharge. That is one reason why the Navy and 
the Army enlisted men or officers dislike very much to come to the 
attention of the psychiatrist, for fear that a diagnosis of this sort 
will be made, which will mean in turn a threat to their security. 
It is one reason in view of that fact, which can’t be denied, that 
probably we ought to coin some new term. I am not sure that war 
nerves is the best or fatigue syndrome or whatnot, but something, 
just a new word. After all, that is one of the principal pastimes of 
psychiatrists, perhaps. (Laughter) 

In the case of the merchant seamen, there arc two factors in¬ 
volved: one that he has no opportunity for compensation, but his 
pay is stopped while he is laid up; on the other hand, the history of 
having been even in a hospital or in a rest home with a diagnosis 
of psychoneurosis is not going to militate against his getting another 


/ 


82 


TRAUMATIC WAR NEUROSES 


job. In fact, I rather guess sometimes some of these men go back 
to work before the doctors would recommend it. i 

Dr. Parran: May I ask Dr. Overholser a question? At St. 
Elizabeth’s Hospital, Dr. Overholser has both Navy patients and ^ 
Merchant Marine patients. Do you detect the differences which have 
been suggested, and by other speakers rather denied, as between 
the reactions of those two types — reactions as patients? ; 

Dr. Overholser: Since Pearl Harbor we have had only about ' 

ten merchant seamen at Saint Elizabeth’s, ranging in age from 21 to ^ 

68. Six of the ten were diagnosed as schizophrenia; the rest were ^ 

scattering in diagnosis. Most of them had conditions of rather long j 
standing, as compared with the Navy patients, many of whom show 
acute situational states. The factor of rigid military discipline, which 
seems prominent in the Navy cases, is of course not present in the 
merchant seamen. 

Chairman Ruggles: Thank you. Dr. Overholser! 

We are honored in having here one of the Flight Surgeons of 
the Canadian Flying Corps. We would like very much to hear from 
him. 

\ 

Dr. C. G. Stogdill: My work in the Air Force has been entirely 
concerned with selection, so I don’t feel that I have a great deal 
to contribute to this discussion. One thing I would like to mention, 
however, following a remark of General Grant’s. I have been told 
that in the detection of what is called “flying stress” in the Royal Air 
Force, the men who are recognized by the M, O’s as showing 
symptoms indicative of “flying stress” and are then taken off flying 
for a time are likely to return to flying. Whereas, of the men who 
are not detected before they themselves come and ask to be taken 
off flying, a large proportion do not return to flying. 

How applicable this is to the merchant seamen problem I don’t 
know, or whether there is any possibility of recognizing the men who 
are showing signs of stress. 

Chairman Ruggles: Dr. Brill! 

Dr. a. a. Brill: I just wish to make a few remarks apropos Dr. 



TREATMENT 


85 


Kubie s statement that the patients are most nervous as they fall 
asleep and when they wake up, and he thereupon suggested prolonged 
sedation. Now, long ago, when I was still worrying about my pa¬ 
tients’ insomnias, I tried to find out why they couldn’t fall asleep. I 
then found that the popular conception of counting sheep in order 
to fall asleep is based on psychological facts. For my insomniacs were 
kept awake because they could not center on one idea. Their minds 
wandered from one idea to another, and as they couldn’t center on 
one interesting idea, they couldn’t fall asleep. 

I then suggested that they should center on one idea, which 
was important to them. In addition, instead of giving them seda¬ 
tives, I gave them some tonic, usually a fiftieth of a grain of strych¬ 
nine. This overcame their incapacity to adhere to one idea and, 
believe it or not, many of them were actually benefitted by it. I 
merely offer it as a suggestion. 

Just one more minute, apropos Dr. Overholser’s suggestion to 
placate the Navy by inventing some new term for psychoneurosis— 

I cannot see why we should be afraid of telling the patient he is 
nervous. We have been trying all these years to educate the public 
that there is no crime or ignominy in being psychoneurotic. Why 
should we now invent a new word for it, why should we run away 
from the truth? Why not educate the naval authorities to the fact 
that it is not a crime to be nervous? 

Chairman Ruggles: There is just a minute left. I am going 
to ask Dr. Blain to close this session. But there is time for one 
more speaker before that, if anyone has any questions or anything to 
offer. 

Dr. Leslie H. Farber: I would question Dr. Sherman’s statement 
about the relative lack of morale in the Merchant Marine, as com¬ 
pared with other branches of the armed forces. My experience has 
been just the opposite. The merchant seamen I have seen at the 
Marine Hospital in Norfolk have had unusually high morale, which 
I had attributed partly to their unique morale-building agency, 
the National Maritime Union. I think it is unfortunate that no 
one has so far discussed this element in morale. 

From what I have observed, the union operates efficiently as a 
highly protective parental organization which not only protects the 
rights and privileges of its members, but actively encourages and 


84 


TRAUMATIC WAR NEUROSES 


rewards both individual and group heroism. Even while in the 
hospital, the seamen maintain contact with their delegates. In fact, 
many of them regard the union as the most important single rela¬ 
tionship in their lives. Since good morale is one of the most import¬ 
ant safeguards against neurosis, as well as a primary factor in its 
treatment, it seems to me that this program would have to include 
a close, cooperative working arrangement with the union. 

Dr. Edward A. Strecker: Dr. Ruggles, I would like to ask Dr. 
Blain if he has time to touch one point which seems to be the most 
important point in the therapy and has a direct relationship with 
chronicity, and which is obviously a handicap to the Merchant 
Marine. I refer to the possibility of establishing more immediate 
treatment, directly on some of the ships, possibly through men 
who are trained a bit in first aid. Perhaps quicker contact could be 
made with hospital ships or other agencies. 

Chairman Ruggles: Thank you. Dr. Streckerl 

I am going to ask Dr. Blain also, in addition to that, because 
I don’t know in my ignorance whether the Merchant Marine has 
any chaplain service at all that might be utilized in this way, but 
if you would speak of that, I would appreciate it. 

Dr. Menninger has a word he wants to bring us. 

Dr. Karl Menninger: I haven’t had any experience in treating 
these individuals with the anxiety precipitated in this dramatic 
way, but I spent the early hours of this' morning cruising around 
over New York in a snow storm, unable to land, and thus made 
some personal observations on anxiety. 

I have recently had an opportunity to study one of the captains 
of one of these merchant ships, which is the background for some 
comments that I would like to make on Dr. Sherman’s paper. I 
thought his report was extremely interesting, but it seemed to me 
that something more might be made of the point that Brigadier 
Chisholm developed, a principle of therapeutics that we all know 
but are apt to neglect. That is the principle of dispersing aggressions 
in some acceptable way. I was impressed, too, with what Dr. George 
Daniels remarked about the ease with which in group therapy the 
leader was singled out for such discharges of aggression. 

I am particularly interested in group phenomena and in this 
discharge of aggression toward the leader of a group, not only as 


TREATMENT 


85 


president of a psychiatric organization but also as a clinician. In 
our clinic, this device is regularly used as a method of treatment. 
It seems to me that we could give quite a little more thought to 
two aspects of that; (1) how such aggression can actually be encour- 
aged, endorsed or utilized therapeutically; and (2) what becomes 
of the aggressions in those instances in which all symptoms subside 
under a regime which is entirely benevolent and in which the whole 
element of aggression seems to evaporate magically. 

In most institutions where group therapy is in practice, one 
hears a great deal of “griping” and it is the impression of some of 
us that this is a very healthy device. In our own institution, we 
encourage “griping”. I read somewhere that the army encourages 
“griping”; whether they do or not, we all hear a lot about it. 

Now, what is the therapeutic effect of “griping” and what is the 
prophylactic effect? The latter we might discuss this afternoon. 
The therapeutic effect, I think, is important. What I am most im¬ 
pressed with is that it is difficult to find leaders who are able to take 
it. It seems to me that as medical men who are in the position of 
being therapeutically helpful to groups providing we can take the 
criticism and the abuse and the aggressions which we know are not 
intended for us, but which arise out of the anxiety and the freed 
aggressions which these acute illnesses precipitate. If there could 
be some general recognition that this a part of the process, then it 
might enhance the therapeutic effect by diminishing our defensive¬ 
ness. My impression is that the doctor, not always remembering 
this or not always knowing it, is sometimes so defensive against 
the aggressions that are directed toward him as leader of the group 
or leader of the treatment, that the defense reactions on his part 
unintentionally defeat a good deal of the therapeutic program, no 
matter how ideal and intelligent it may be. 

I was going to make some remarks about my captain, but I will 
do that this afternoon, if I may, in connection with prophylaxis. 

Chairman Ruggles: Thank you I Dr. Blain, will you conclude? 

Dr. Daniel Blain: I might say that it was part of our idea to 
start out with a certain subject, and not to digress too far in the 
discussion, but that as the day went on, every subject would merge 
with the subject preceding it and so on. So that this afternoon we 
may expect to hear something about practically everything connected 
with the whole subject, even though we are always talking about the 



'’■'' /'*j ' '- ''• i> 'j 'V-. ‘ *■..■; •^'■i ■ ' ’ ■ ' ' ■' 



86 TRAUMATIC WAR NEUROSES 

general subject of prevention. I have a feeling, now that we 
have had a couple of laughs in the last few minutes, that we have 
begun to warm up to this subject. I am looking forward to the after¬ 
noon with keen anticipation. 

Several questions I can answer right now. One is in regard to 
neurological checkups. Every patient we have is checked previously 
by doctors of the Public Health Service in the Marine Hospitals or 
the Marine Clinics. We are forearmed with the findings on the 
neurological side. I am not in a position to give you any informa¬ 
tion on the subject. We have had, so far, 300 cases. Our program 
has been gathering momentum until only two weeks ago we opened 
a center in Louisiana, and next week we will open one near San 
Francisco. So that in the next two or three months, we will 
probably accumulate a great deal more data. 

I think that when the May meetings are held we will be able to 
give, in formal papers, some real conclusions founded on quite a large 
amount of material. 

We tried to break up our group thus far, but the cases are really 
so few when we come to divide them into small groups, that we have 
no inclusions in this respect that we can even talk about at the 
moment. 

With regard to the armed ships versus unarmed, I think in our 
records we will be able to find the answer to that question. There is 
no question but that the men talk about it all the time, “Well, I 
was on a ship that wasn’t armed.’’ But more recently we don’t hear 
that so much. That is correct, isn’t it. Dr. Sherman? 

Dr. Sherman: Yes. 

Dr. Blain: The doctors are seeing the cases. I don’t see them 
so much any more. But the real point at issue is whether the people 
of the United States are looking after the seamen and are interested 
in them or not. Part of looking after them is putting guns on their 
ships and part of the whole ^morale problem, therefore, is brought 
up in this general subject of whether they do better with arms or 
without arms. 

I want to say while I think of it that we are handicapped. 
Doctor, because Dr. Howard Potter, who is on a half-time basis with 
us and in charge of all the work in the New York area, unfortunately 
is laid up with laryngitis and couldn’t come today. I want you to 
know he should have been here and we count him as one of our 
mainstays in the whole program. 



r 


,V 


treatment 87 

4 

With regard to cooperation with the unions, I know from the 
history of the Orient, that in China they got away from the govern¬ 
ment by forming their own trade guilds, looked after their own 
affairs, took care of a great many of their own troubles. 

The merchant seamen have done exactly the same thing. There 
are some ten or fifteen different maritime unions. 

I will say that the unions themselves are very vital factors in the 
morale of the seamen. They have done, I think, a great deal for the 
seamen and certainly they are doing a great deal now in the way of 
services that are given to the seamen and in adjusting grievances. 
They are very important. We cooperate with them very closely. We 
see their leaders continually. We have patients referred by them. 
They have come out to our places, and we foster the brotherhoods 
that they happen to belong to, no matter what it is, in every way that 
we can. 

There are a small number of seamen who don’t belong to any 
union, and a larger number of officers who don’t belong to a union. 
As far as we are concerned, we don’t care whether a man belongs to 
a union or not. We don’t ask him, but we generally find out sooner 
or later. 

So, eventually, I think we will have some figures on that matter. 

Dr. Strecker’s question with regard to earlier treatment, I alluded 
to briefly. It is theoretical, of course. We are preparing to put 
material on ships to get these men ahead of time. That is part of our 
prevention scheme. 

As to the question about chaplains, the seamen themselves pub¬ 
licly and through their leaders say they don’t want anything to do 
with religion. That is true of most of the unions. We didn’t pay 
too much attention to that. On the other hand, we didn’t do any¬ 
thing about it. We let the neighborhood influence our centers as 
the neighborhood wants to influence them. The result is that 
preachers and priests have come to all of our homes and the men are 
welcome to see them or not, as they please. 

I was very much interested to find about three-quarters of all 
our seamen go to church every Sunday. It is entirely up to them. 
They get good spiritual care, because it is there if they want it. If 
they don’t want it, we take a neutral attitude on the subject. 

I think that is about all at the moment. Doctor. Maybe before 
the end of the day I shall have more questions to answer. 

Chairman Ruggles: Thank you. That concludes our time. 



88 


TRAUMATIC WAR NEUROSES 


and I will turn the meeting back to the Chairman, Dr. Parian. | 

(Surgeon General Parian resumed the chair.) s 

Chairman Parran: Thank you very much, Dr. RugglesI 1 

Before recessing for lunch, I would recall that, as was stated in 4 

our invitations to you, this meeting is made possible and certainly | 

made much more successful as a result of the cooperation of the 
Josiah Macy Foundation.* I should like to recognize Dr. Fremont- - 

Smith, of the Josiah Macy Foundation. Have you any accountments 
you would like to make? j 

Dr. Frank Fremont-Smith: Thank you, Dr. Parran. I simply | 

wish to tell you how delighted we are that you are here and that you ! 

have given us the opportunity to collaborate with you and with the i 

Academy. Dr. Rappleye, president of the Foundation, telephoned 
me a little while ago to say he had been called to Washington, and 
wished to express to you and Dr. Blain his regret that he could not 
attend. 


♦Financial support for the Conference was also provided by the War Shipping Admin¬ 
istration and United Seamen’s Service. 






PREVENTION 













/ 

i 











AFTERNOON SESSION 


PREVENTION 

The conference reconvened at 2:30 p.m., Eastern War Time, 
Surgeon General Thomas Parran presiding. 

Chairman Parran: We shall continue the discussion this after¬ 
noon on the subject of prevention. The leader of the discussion 
will be Dr. Karl Bowman, of the University of California. 

Dr. Karl Bowman: Dr. Parran, Ladies and Gentlemen: I am 
informed that in the discussion this afternoon we can bring in all of 
the subjects that we have discussed before; so that you should feel 
free to bring in anything in the way of etiology and pathology and 
anything in the way of treatment. We shall focus on prevention, 
however. 

The problem of the prevention of the fear neurosis or war nerves 
can be presented, of course, from many angles. I hope that is what 
we will be able to do this afternoon. Unfortunately, in psychiatry 
prevention is not as simple as is the prevention of certain physical 
diseases like typhoid fever or smallpox, where we can inoculate a 
person with a dosage of a certain drug or serum. 

' We will start the discussion this afternoon by calling upon Dr. 
Grace Baker, who is the physician in charge of the Rest Center 
at Baltimore, Maryland, and who will be able to present her material 
from the practical standpoint of one who has had experience in 
working with this problem. Dr. Baker! 

Dr. Grace Baker: War neurosis is a prolonged fear reaction to 
war experience. It is an over-reaction, not an illness in itself. Any 
planning for prevention, therefore, should be directed toward pre¬ 
paring individuals with the physical and psychological means for 
adequately meeting danger. We all recognize that danger admitted 
better prepares an individual, certainly psychologically, to deal with 
it. The known is less feared than the unknown. Admitting the 
danger carries with it the implication that something can be done 
about it. It tends, therefore, to eliminate or prevent feelings of 
helplessness or despair. 

False reassurances are out, but every possible means of safety 

91 


92 


TRAUMATIC WAR NEUROSES 


should be provided and made known to the seamen, with clear ex¬ 
planations of why they are useful. 

I think the importance of explaining why they are useful is indi¬ 
cated in a story that was told me. As perhaps you know, every seaman 
is provided with a knife. This perhaps could make no sense to him 
unless he was also informed that the knife may be of help to him in 
case he is thrown into the water, in helping him to attach himself to 
a raft where he can hold on until he is drawn to safety. 

I think the factor, therefore, of explaining why each thing they 
are instructed about, what the purpose of it is, is very essential. 

Measures of protection, strictly speaking, fall into two classes. 
First, what can be done to combat the possible real danger. Second, 
what can be done to prepare the individual, physically and psycho¬ 
logically, to deal with it. This should include all the unusual com¬ 
mon sense rules toward achieving and maintaining good physical and 
mental health. 

The basic principles should be directed toward building self- 
confidence, a sense of security, that is, a good healthy sense of self¬ 
esteem. 

We all know the value of attention to any physical difficulties. 
Any physical ailment can prove a great irritant when we are under 
any strain. Attention to fatigue is particularly important. Regular 
furloughs are indicated. Frequent, if possible, but not for too long 
duration. 

One suggestion would be recreational camps. Here men would 
be with those they are accustomed to, but if possible, outside visitors 
should be interested, which will tend to create a feeling that the men 
are respected members of the community. 

If at all possible, individual conferences with the men should be 
held to provide an opportunity for discussing any of their worries. 
We all admit the value of discussing a problem. It creates a feeling 
that someone cares and many times something can be done to ease 
the worry. 

I think the experiments in industry have proven the value of this. 
As you know, various experiments in trying to increase the output 
of men and women during times of particular pressure like war have 
been carried on. They tried rest periods; they tried changes in lights 
and color and food, and so on. But they finally concluded that the 
individual conference with the man where he had an opportunity to 
talk over his problem seemed the most beneficial. I think the real 








PREVENTION 


93 


basis of this comes from the fact that he feels that his welfare is of 
importance. 

In giving the instruction regarding methods of combating the 
danger, the teaching should be given seriously and with confidence. 
It should be accurate and detailed regarding every lifesaving device. 
That is, I think it should have to do with frequent and constant 
drills as to how to abandon the ship, how to seek safety in times of 
bombing, how to get the rafts off the ship, how to swim, how to 
get into the lifeboat, and then very particularly how he can protect 
himself after he is in the lifeboat. 

Some experiments carried on by Dr. Mussen and presented to 
us by Dr. Willoughby, I think have outlined the problem very care¬ 
fully and show the value of this procedure. The man should be 
informed on how he should behave once he gets on that boat, what 
is the value of food, water, sedatives, and so on. Such information 
has value, not merely because it may save his life if the danger strikes, 
but at the same time it tends to create confidence. If^drilled properly 
and frequently, he is trained to react more or less automatically and 
intelligently. It acquaints him, however, not only with the means 
of safety available, but produces the feeling that someone is planning 
for his safety. It creates, therefore, a feeling that he is valuable. 
When he sees other men similarly instructed, it reassures him that if 
he should become incapacitated others are equipped to aid him. 
This avoids the sense of aloneness. Such group instruction and drill 
therefore seems essential. 

In addition to these physical methods to aid him, instructions 
should include some of the physiological signs of fear. We should 
understand these signs not as evidences of dying but as good and 
healthy indications, since they are the defensive mechanisms of the 
body to warn us in times of danger. The anger which follows is 
also legitimate and desirable. To object to aggression, resent it, is 
the body’s defense mechanism; we have to defend ourselves and it 
therefore is quite proper and desirable. Many of the symptoms in 
the men have developed after they have reached safety. Their his¬ 
tories indicate little apparent upset about the trying experience itself. 
They appear to be reacting to what they consider evidence of neglect 
or failure of the individuals with whom they come in contact to 
appreciate the difficulties they have endured. Every effort, therefore, 
should be made to include in our programs all individuals who deal 
with these men. 

I have wondered if these complaints are the real cause of the 


94 


TRAUMATIC WAR NEUROSES 


disorder, or are these delayed reactions due to the fact that a man is 
harboring the fear that he didn’t do as well as he should in the crisis? 

He should be met with a sympathetic attitude and an honest 
regard for the hardships he has endured, but the emphasis should be 
put on a healthy respect we feel for the courage he has shown. Some 
official recognition and reward in the way of a ribbon or a medal 
would be useful. For the man who is broken down in the crisis, 
treatment should be considerate and it should be frankly admitted 
that the illness is unfortunate. 

In order to avoid long illnesses and particularly with the aim in 
mind of preventing recurrences, the emphasis should be directed 
toward discussing with him all the possible factors that might have 
brought about the unfavorable results. This frankness creates the 
impression that such undesirable reactions can be treated and pre¬ 
vented. Any coddling attitude such as high compensations or too 
much sympathy should be avoided. Breakdowns shouldn’t pay. 
Don’t dramatize the sick but the one who stood it well. 

I think that one plea I should like to make, too, in understanding 
the seamen is something to do with how little we know about him. 
As far as I can see, the general public’s chief point of information 
about the seaman is that he is a drunken sailor. I think it is very 
important to emphasize that when he is drunk, he is off duty; also, 
that the alcohol is very frequently his way of treating himself. I 
think we can’t deny that in many cases it has usefulness. I think 
that this is a very important thing because in the alcoholic seamen 
that I have seen, there is marked sensitiveness to their alcoholism. 

To sum up, in our training, therefore, we would attempt to 
emphasize the important methods of his physical safety which is so 
essential. In so doing we stimulate or create a sense of self-esteem 
and provide justified reasons for self-confidence and a sense of secur¬ 
ity. We emphasize, too, that anger and fear are justified, but not 
despair. In other words, to be alive is power. 

Chairman Bowman: Thank you. Dr. Baker! 

As many of you probably know, in setting up these homes, an 
attempt has been made to link them up with some medical school. 
This home in Baltimore is linked up with the Johns Hopkins Medi¬ 
cal School, and so I think it is appropriate to ask Dr. Whitehorn if he 
has any further contributions to make at this time. 

Dr. John C. Whitehorn: My actual knowledge of these matters 



\ ■ * s 




PREVENTION 95 

is almost all by proxy through Dr. Baker, and I could only comment 
intelligently by echoing what she has said and by stating my reactions 
to the other discussions today. 

One point stands out in my mind very strikingly. That is the 
very definite attempt on the part of every one to keep the treatment 
and preventive program on a highly practical basis and to avoid 
so far as possible too much meddling with the background of the 
patient. That has even reached in certain people’s remarks the 
extreme of wishing to avoid any of the terminology which would 
seem to imply an unstable background. I think in that connection 
the work that Dr. Baker has done, with which I have been a little 
familiar, has shown the value of having a well-trained and experi¬ 
enced psychiatrist in a key position where the practical program of 
treatment and prevention can be scheduled and carried forward 
with somebody in position to see the cases that it won’t quite click 
with and to provide other disposition for those. 

I think if we were to schematize too simply the whole treatment 
program and turn it over to other personnel, we would miss just 
this important consideration. 

Chairman Bowman: I am going to call next on Dr. Felix, who 
is teaching psychiatry to the officers and men at the Coast Guard 
Academy. He may have something to contribute along this line. 

Dr. R. N. Felix: Mr. Chairman, I don’t know exactly what I 
can contribute from my experience. I am a psychiatrist at the 
Coast Guard Academy at New London, Connecticut. My job is 
mostly concerned with selection and assisting in indoctrination of 
the reserve and the regular cadets of the Coast Guard who have their 
period of training at the Academy. 

Perhaps I should remark that one difference which I have noticed 
between the problems that have arisen among the Coast Guard 
enlisted personnel and among the maritime personnel is a feeling 
of lack of permanence among the latter. I see the prospective 
licensed officers in a consultatant capacity while they are in the 
training school at Fort Trumbull; I think that was mentioned this 
morning. The merchant seaman is attached to a ship for one 
cruise and then may go to another; while our Coast Guard enlisted 
men, of course^ are assigned to their ship for an indefinite length 
of time and remain as part of the ship’s company until they are 
relieved. Therefore, they develop a certain bond, a certain feeling 


96 


TRAUMATIC WAR NEUROSES 


toward their officers, which it has not been my experience to find 
among the maritime enlisted men in every case. 

I don’t know whether Dr. Menninger had something like that in 
mind this morning, when he started to talk about his captain, or not. 
I think there is something there worth delving into. 

The Coast Guard enlisted man gets a certain amount of transfer, 
emotional transfer, to his officer. He looks upon him in quite a 
different way from how I have felt the merchant seaman looks upon 
his ship’s officers, which brings up the point that perhaps as much 
attention should be paid to the selection of the licensed officers in 
the maritime service as we are trying to pay in the Coast Guard. 

In my work in that respect, I am using a battery of tests, in 
which I am trying to find some help in selecting these men. Each 
of them also fills out a personal data questionnaire which I have 
found of great assistance. Incidentally, if the war lasts long enough— 
I now have data, a rather complete set of data of 1500 college 
graduates from all over the United States who have gone through 
the Reserve Officers’ Training School at New London, and, without 
hoping the war lasts too long, I hope that I can run that up to 
3000—perhaps I can find something worth while there. 

In addition to this, every prospective officer, whether he be 
reserve or in the regular program, is given a personal interview. 
In the Reserve Training School, there are about 275 entering every 
month. We have a four months’ course. I see them for only ten 
minutes on the average. However, on that basis I am able to draw 
some conclusions probably somewhat snapshot in nature about the 
men, aided and abetted by my psychological and adjustment tests 
which I try to give them. I am using the Bell personal adjustment 
inventory, the American Council of Education psychological test, 
the Minnesota form board test, and a mechanical aptitude test. 

On the basis of this, I think we are doing a little better job in 
picking the kind of man who will be adaptable to the responsibilities 
which he must assume very shortly after he graduates. I think that 
one of the reasons why the Coast Guard enlisted man has a feeling 
of confidence and security in his officers when he goes aboard his 
ship is that he feels his officers are adequately trained, that they have 
been selected not only for their technical ability but for their 
leadership capacities. 

I have thought as I heard the discussion through the morning 
that while I am still unconvinced there is any difference between 
a war neurosis and any other type of psychoneurosis which I have 



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seen, nevertheless, the precipitating factors are somewhat peculiar 
here and to a great extent depend upon the officer material which 
the maritime service can provide to man their ships. 

Chairman Bowman: I am going to call next on Dr. William 
HoflEman, of the Norwegian Public Health Service, who is at present 
in charge of the 100-bed convalescent home for Norwegian seamen 
at Chester, Nova Scotia. Perhaps he can tell us a little of his 
experiences and give us something of value. 

Dr. William Hoffman: Thank you, Mr. Chairman! 

I should like, first, to express my gratitude for having been 
invited to attend this meeting. I have been very interested in hearing 
not only the presentations but also the various viewpoints on these 
cases. 

What I would be able to contribute would be some figures as 
to the frequency of these cases. The convalescent home at Chester 
is accepting not only torpedoed crews, or nervous conditions, but 
all kinds of diseases. It has been at work since June, 1941. I have 
reviewed the number of cases we had during the year 1942—that is, 
cases I have mainly seen myself. 

During the year 1942, about 25,000 Norwegian crew members 
visited Halifax. That means 25,000 single trips, all of them having 
been exposed to some extent, all of them having arrived at Halifax 
through the danger zone. At the same time, during the same year, 
296 men were sighted off Halifax after having been torpedoed. Of 
these approximately 300 men, only nine were admitted to the con¬ 
valescent home because of nervousness. The rest of these men, 
290, represent on the one side our lack of information, and on the 
other side they represent those that take care of themselves. That 
means that they are drifting along ashore for a month or two, and 
when their money is gone, they finally turn up at the shipping 
master’s office, in the meantime having what perhaps we now should 
call alcohol nerves. 

I would like to digress from these nine cases and explain that 
among the cases I see in Halifax, I have many coming from other 
parts of the Western Hemisphere. They are not all coming through 
Halifax, but the greatest proportion of the 300 did. They are the 
only statistics I can give as to the frequency because I have not 
material to show how many have been torpedoed in other parts of 
the Western Hemisphere. 


98 


TRAUMATIC WAR NEUROSES 


< ; 

^ ./ 

. During the year 1942, I had 60 psychiatric cases at the convales¬ 
cent home. Half of these cases are not pertinent to our question 
today, consisting of questionable syndromes and patients with other 
organic determining factors or major psychoses. In spite of that, 

I really think some of those major psychoses are reactions to the 
war situation in a more special sense. Some are due to life-long 
constitutional make-up. The other half really belong to the group 
we speak of as having “nerves.” Now, happily, just half of this 
group do not blame the war or war experiences for their nervous 
condition. That is, more generally maladjusted people—people with 
dyspepsias, with or without ulcer, and slight alcoholism. 

In only half of this group of 30, I mean this group of general 
maladjusted people, there is no obvious connection with the war 
situation. There may be one, but it isn’t apparently connected with 
the war situation. And they do not blame the war situation them¬ 
selves. The main thing, of course, is that you are able at least to 
indicate with some certainty that these people have not been well 
before. 

This other group of 15 cases, 9 of which came from Halifax, are 
really war nerves. That does not mean, however, that we can blame 
a certain incident during the war; nor does it mean that these 
people have been nervous following an explosion or a certain detona¬ 
tion. Practically all of these 15 blame a certain trip. They tell that 
they had been attacked during five days or two weeks, and they blame 
a certain trip. I think that some of them are right so far. I have at 
least two cases in which, I am sure, as far as I am able to judge, 
there was no insufficiency before that. 

Many of them are simply afraid because they are at war and they 
have been impressed particularly by a certain trip. Afterwards they 
think themselves, and they tell us, that it is mainly due to that trip. 
I think the situation is rather the opposite. They are generally 
afraid and on that occasion they got a demonstration of what you 
can get into. But there are some cases, really, where you have a 
feeling that they have felt entirely well before and after having 
been attacked during those days they have been torpedoed and got 
aboard a rescue ship. But after having had this experience, they 
have developed a more acute picture. 

Now, as to the question of the more strict causes of this, I think 
it should be considered that one of the main symptoms is sleep dis¬ 
turbance. This is not coming on the individual as something from 
the outside, but the man is starting his sleep disturbance himself by 


PREVENTION 


99 


V*- 


not going down in his cabin. Many of these people stay on deck and 
sit around in the dining room, and so on. They are starting to 
develop unhappy habits and I am not thinking of drinking. There 
is very little drinking. So down in the cabin they finally pull them¬ 
selves together. They go down to the cabin and they tell about the 
peculiar sleep disturbance that I have not heard of before. It may 
exist in other conditions, too; namely, they do not tell, as many 
psychoneurotic patients tell, that they have experienced only sleep for 
a short while, and you discover that they have slept a long while. 
They tell that they waked up and thought they had been sleeping 
for hours and when they looked at their watch, they had only been 
sleeping for a few minues. 

Sometimes they say, as we have heard before, that they do not go 
to sleep really, but they have kind of dreamlike states, where they 
are imagining all these things that occur. 

I have not been able to see any difference between the men who 
have been aboard tankers and men aboard freighters. In spite of 
this, I have a special respect for the tankers. But there is a definite 
difference between the engine and deck men. The engine people are 
more apt to be nervous than the people on deck. There is a further 
difference. These people who have to take care of the engine be¬ 
tween four and eight are particularly afraid. Of those who are on 
duty between twelve and four, some of these engineers have told me 
that they have started being nervous because of the responsibility. 
The engines are not working as well as during peacetime. That is a 
result of this slow going in the convoys; a ship able to make twelve or 
fourteen knots has to go nine knots, and then they have to stop and 
go and stop and go. Then they start thinking about the fact that 
they do not have the proper reserve parts, and they start wondering in 
the cabin when they are off duty whether everything is in order, and 
they have to go down and see if everything is as it should be. 

I have observed one peculiar feature of these pictures I might 
mention. Some of these boys are particularly afraid of the alarms. 
It doesn’t sound so astonishing if you take it that way, that the alarm 
means something is wrong; but, on the other hand, this tremendous 
noise of the alarm seems really to startle them. We have something 
similar in animal experiments, as you know. Noises are particularly 
disturbing. I have heard of people who have entirely lost peace of 
mind, in spite of the fact they were on deck, because of the repeated 
and tremendous use of alarms every five, ten or fifteen minutes. It 
excites apprehension. 


100 


TRAUMATIC WAR NEUROSES 


But, on the whole, I think that the question of prevention is a 
question of efficiency and it is a question of reduced danger. The 
thing we can do, perhaps, is to organize the Merchant Marine some¬ 
what better, as Dr. Evang mentioned earlier this morning. I mean 
it is unfavorable that the Merchant Marine, differing from the armed 
forces, is so loosely organized. The men are signed off and are more 
or less left to themselves when they sign up again. In a certain sense, 
though, they are called upon, but they are going nonetheless to 
another boat. They are sometimes going with people who are not 
congenial to them. 

What we do is to approach the situation as we do within the 
armed forces. The Norwegian Seamen’s Union (there is only one) 
has recently done something about that. It has been able to get 
through a rule that when a Norwegian sailor is signed on and has 
been torpedoed, after having sailed for a long time, he may have a 
vacation of a month; but after that time, he is entitled to sign 
on if there is a ship, or if there is none, then he will at least have the 
feeling that from that time on, he still belongs to the Merchant Ma¬ 
rine. An ideal situation would be if these men were taken by the 
Merchant Marines of different nations and signed on for the duration. 
Then, they would get their furloughs when they are left more or 
less on their own. They shouldn’t have the same strict discipline as 
other men of the armed forces, but they should have the feeling that 
they belong to the Merchant Marine for the duration. 

Chairman Bowman: Thank you. Dr. Hoffman! 

This morning we had a considerable discussion about whether we 
needed a new name for war neuroses or psychoneuroses, and it was 
suggested that there was a certain stigma carried with this term and 
that in certain of the cases it was much more a normal state of fatigue 
than it was something to be christened with a name suggesting an 
abnormal state. 

I believe that Captain Marsteller has a new suggestion that he 
might like to make at this time. Captain Marsteller of the U. S. 
Navy Medical Corps! 

t 

# 

Dr. a. a. Marsteller: I think this morning I did not make 
myself quite plain to Dr. Brill. I am thoroughly in accord that we 
should make an attempt to teach and indoctrinate our men, but to 
do this we must start with the families before the men enlist. At this 
time—that would be during a period of hostilities—we just haven’t 


PREVENTION 


101 


the time to do that. So that my feeling is, that inasmuch as many of 
these reactions are normal reactions, or exaggerations of a norm, 
we might call them for first admission, say, combat fatigue. Then 
later, if after study it was determined that these people had actual 
neuroses, it would be all right to go ahead and give them a diagnosis 
of the appropriate neurosis. 

Another thing I want to mention is in connection with Dr. 
Baker’s talk. I was very glad to hear her bring up the question of 
alcoholism. Alcohol is always quite a problem to the military serv¬ 
ices. However, we are in the habit of differentiating the alcoholic 
who resorts to it as an escape, either from a situation or from his own 
conflict, and the social alcoholic; say, a healthy Marine outfit that 
does a good job, meets a situation, handles it, and then goes ashore 
or goes off and celebrates in a big alcoholic spree. I was very glad to 
hear how Dr. Baker handled that subject. 

Chairman Bowman: There are certain services that are making 
special efforts at prevention. I believe Dr. John Murray, who is a 
Major in the Medical Corps in the Army and is doing some work in 
prevention work in the Air Forces, can tell us of his work. 

Dr. John M. Murray: I thought you might be interested to 
have a brief summary of the work in the Air Forces in relation to the 
prevention of mental illness by our attitude toward the early neurotic 
symptoms. 

Now, the Air Forces are so organized that the basic unit in this 
endeavor is the flight surgeon. First, we need to define the flight 
surgeon. What is his basic task? His basic task is the maintenance 
of personnel, particularly in the combat situation. He is attached to 
a combat unit in charge of the health of his group. The health of 
his group comprises both the physical health and the mental health. 
It is amazing to see how much these young doctors, these young flight 
surgeons, are interested in this special aspect of their work, most of 
them with no training, especially, in psychiatry. Yet fundamentally 
they are very good doctors, most of them experienced in practice of 
some of the specialties, but the great number of them as successful 
general practitioners. 

It is amazing to see the amount of real need which these men have 
for a psychiatric understanding, realizing what their problems of 
maintenance in the field are going to be. These men are rather 
carefully selected and hand-picked before they are sent to the school 


102 


TRAUMATIC WAR NEUROSES 


to become flight surgeons. They are chosen, of course, for the charac¬ 
teristics that are obvious. First, they must fundamentally have been 
good doctors and must, of course, have completed work with the 
Army that is satisfactory in bringing out their integrity, scientific 
interest, special intellectual abilities, and so forth. 

Having been selected on this basis, they are sent to school for a 
very, very intensive three months’ course. This three months’ course 
is divided in two sections. The first six weeks comprise a strenuous 
course of instruction by, if I may say so, superbly qualified teachers 
in the medical specialties that these men are going to need in the 
field. The first specialty that is of great importance is the eye. The 
suffering from oxygen deprivation, anoxemia as we call it, has a tre¬ 
mendous tendency to bring out night flight diplopia or any latent de¬ 
fect in vision. It seems the eye is the first organ to be affected by this 
situation, and so these men must have almost perfect ocular equip¬ 
ment. 

The flight surgeon, first, has to be trained to be almost a specialist 
in optics. And he gets that training. Next, of course, is the circula-' 
tory apparatus, and they throw a mean cardiology at you there. I 
know that, because I have just come through it. As a matter of fact, 

I have just finished my three months’ course, and I am well aware of 
the intensity and extensiveness of the knowledge in cardiology which 
one has to have in this school. 

From there they go to tropical medicine. Tropical medicine is, 
of course, a vitally important subject for these men to know in order 
to prevent epidemics of all the various tropical illnesses which they 
have got to encounter in the regions where they are bound to be 
serving with their combat units. 

Well, we go on to military sanitation and so forth and so forth, 
the other things that are obvious; but we will end up by coming to 
psychiatry and there they are given fine courses in psychiatry. Many, 
many of the young men came to me during the course, or near the 
end of the course and said, “For God’s sake, why didn’t they teach us 
psychiatry like this in medical school! This really makes sense.’’ 

I say to them, “Well, psychiatry has advanced since you were in 
medical school; maybe they threw you something like that in medical 
school and you weren’t so interested as you are now.’’ 

“Well,” they counter, “I don’t know what it is. This certainly 
makes sense to me and I wish I could get more of it.’’ 

I will deviate for a moment, if I may, to tell you an actual experi¬ 
ence illustrating the expression of this need that happened a few 







PREVENTION 


103 


r* 


weeks ago. Some of the boys with whom I was working at the classi¬ 
fication center in Nashville, said, “We want to have a little get- 
together and go out and have a few beers one evening. Will you go? 
We want you to come along.” 

I said, “Yes, I would like to go.” 

“We have something we want to talk to you about.” 

I was interested, but they didn’t say at the time what they wanted 
to talk about. They got together. This included a group, I should 
say, of seven or eight of the young officers. What they wanted to do 
was to know if I would become sort of the nucleus of a group of those 
boys who would send me interesting clinical reports of the emotional 
problems they experienced handling in the field, so I might have 
them mimeographed and send them around. They said, “We really 
want to get a fundamental knowledge of what goes on- in the nature 
of psychiatric problems in the field, and this, we think, is one of the 
best ways we can do it because certainly one of the most fundamental 
things that we need to be competent flight surgeons is to have a gradu¬ 
ally increasing body of knowledge in relation to the emotional prob¬ 
lems of the flight surgeons.” 

Really, whether this will work or not, I don’t know. I didn’t 
encourage them too much, because I said, “We may find a better way 
of doing it.” It has been a long time since anything gratified me any 
more than to see this special interest as it cropped out among these 
young doctors. 

Well, we now have considered the flight surgeon, what he is and 
the training which he is given. How does he work? He is out in the 
field among his men; he lives with them. He is part of their daily 
life. He knows every one of them, knows them by first name, and 
not only that, but he knows their habits, and he is there to see at any 
moment when the type of man, the individual, gets depressed, or 
when the quiet fellow begins to get a little overactive; he notices the 
fellow who is beginning to drink a little more than he ought to; he 
notices the fellow showing evidences of sleeplessness and begins to 
see the factor of emotional problems that are becoming apparent. So 
that here at this point he should be in a position to undertake ade¬ 
quate treatment, all of which has been very aptly discussed by my 
colleagues here today in this special situation. 

Now, of course, from the beginning of the flight surgeon, we move 
on into the more elaborate aspects of it. Behind the lines we need 
psychiatrists; we need rest homes; we need a rather comprehensive 
setup in order to deal with the problems in the Air Force as wisely 


104 


TRAUMATIC WAR NEUROSES 


and as aptly as they have been dealt with, for instance, in the Mer¬ 
chant Marine, as brought out here today. This, in a way, is 
maintenance. 

General Grant this morning said we have two important func¬ 
tions. One is selection and the other is maintenance. We will need 
during the year 1943 approximately 125,000 aviation cadets for train¬ 
ing. These cadets must be very carefully selected. Some of them are 
going to show evidence of tension, neurosis, but that must be quali¬ 
tatively evaluated, because many lads with tensions may turn out to 
be what we in the common parlance call “hot pilots”. We don’t want 
to reject those, but we need an elaborate psychiatric set-up in this 
organization to adequately evaluate those boys who are good material 
for pilots, those boys whose special emotional development will make 
them good pilots and who won’t go to pieces under the conditions of 
combat flying. We need to follow those boys along the line of their 
training and see that when they begin to show evidences of the in¬ 
ability to take it, they are, as we say, washed out; and from that point, 
again, we have a very important psychiatric function to take these 
wash-outs, to start them over again in a field in the Air Forces where 
they will be valuable to us and will better fulfill their special abilities. 
This, in a way, is what we aim to do and is our task of mental hygiene 
in our branch of the service. 

Chairman Bowman: The problem of prevention has been dis¬ 
cussed from many angles but more by way of the problem of person¬ 
ality, the problem of emotional stress and strain and of social re¬ 
lationships. There has been very little said as to the physiological 
factors which may have to do with morale and the prevention of 
breakdowns, whether drugs, such as benzedrine, may be useful at 
times, to cite one example. One point that might be mentioned is 
with regard to diet. We have heard of dietary deficiencies affecting 
morale and also the lack of salt as affecting the mental state of the 
individual. Surgeon Commander E. M. Mussen, of the Royal Navy 
Medical Corps, has done quite a bit of experimental work in this 
whole problem of salt ond water. I wonder if he would not care to 
talk to us and see whether there is something in that field that is of 
significance to our subject under discussion. 

Dr. E. W. Mussen: I don’t really know how much you are in¬ 
terested in the matter of fluids and diet in shipwreck conditions. I 
can certainly bear out the importance of full instructions to seamen, 


PREVENTION 


105 


before such an occurence as shipwreck takes place. 

The British Medical Research Council has just produced what 
I think is quite a useful booklet on this subject. Many of the facts 
are based on interviews with thousands of survivors, who were ques¬ 
tioned as to every aspect of their time in a lifeboat. This was 
correlated with physiological research into various aspects of mini¬ 
mum food and water requirements. 

The most important matter from a physical point of view in a 
lifeboat is often the water supply. Water rations in our merchant 
ships’ lifeboats give each man of the boat’s full company a total of 
five and one half pints. We found that the best way to use this is 
to give no water at all in the first twenty-four hours, as at this stage 
it would promote diuresis and be wasted. The ration recommended 
from the second day onwards is 18 ounces per man daily. This 
should be continued till there is 20 ounces left per man, and then 
reduced to 2 ounces per man daily. This system is based on the fact 
that man’s minimum requirements of water are at least 30 ounces 
per day. It has been found by experience that 18 ounces of water 
a day is the smallest amount needed to keep a man fit for the period 
usual in lifeboat trips. With lesser quantities than 18 ounces daily, 
rapid and progressive deterioration is bound to occur from the 
outset 

Though large quantities of sea water may cause death, we have 
shown that limited amounts of sea water may be taken without harm 
and with possible benefit. This, however, should not exceed one 
third of the fresh water ration. 

In the early days of the war, one of the main food supplies in a 
lifeboat was a protein containing substance called pemmican. We 
now realize that such substances raise the blood urea and produce a 
corresponding diuresis, which is unfortunate when water is in short 
supply. Accordingly, we now recommend a food ration consisting 
mainly of fats and carbohydrates. 

There are two other matters that were brought up. One is the 
question of staying on deck, which was mentioned by Dr. Hoffman. 
I noticed that at the beginning of the war lots of our seamen de¬ 
veloped the habit of sleeping on deck instead of going down below. 
That was the start of their sleeplessness in many cases. 

The other thing to be mentioned was the fear of the alarms. I 
think that was noticed by a lot of people in England. It was the same 


106 


TRAUMATIC WAR NEUROSES 


with sounds, a sort of reflex, and the sounds of sirens was quite 
enough to set them off in exactly the same way. 

Chairman Bowman: One way of preventing war neurosis has 
been to build up the morale of the group. There has been some 
discussion about building up the morale among the merchant sea¬ 
men. It has been stated that there are certain things that prevent 
building up morale which are not present in the Coast Guard Service, 
the Army and the Navy. Among civilians too, there have been 
attempts to build up morale. There has been a program of educa¬ 
tion by the New York Academy of Medicine, and I believe Dr. Millet 
has had charge of that. I wonder if from his experience in this pro¬ 
gram of working towards civilian morale he feels there is something 
that he can bring over to this problem of morale among the merchant 
seamen. Will you tell us about that? 

Dr. John A. P. Millet: As I have listened to the discussions, Mr. 
Chairman, and as very many aspects of the problems have been 
brought out, I have some feeling that we are veering away at times 
from the specificity of this whole situation. We have a Merchant 
Marine. Our Merchant Marine is different in its traditions from the 
Merchant Marines of other countries. We have had no recognition 
on the part of the public or the government that our Merchant Ma¬ 
rine formed an essential integral part of our national defense in any¬ 
where near the same degree that has been true elsewhere; further¬ 
more, as has been brought out, the profession of being a merchant 
seaman in this country is distinguished by the fact that it is a rather 
individualistic type of occupation that is sought out by certain per¬ 
sons as a solution to problems of their own, whereas, in Europe, the 
Merchant Marine offers a well established profession, with traditions 
inherent in the trade just as in other lines of endeavor. 

I think it has become apparent to all of us, as signalized perhaps 
by this meeting, that the time has come when something very funda¬ 
mental has to be done in the recognition of the Merchant Marine, 
both as a part of our future national system, and as a particular field 
for psychiatric endeavor and contribution. 

I have the feeling at this point that we can afford to give some 
emphasis to what you might call the educational function of psychi¬ 
atry, and that it would befit us well to study every possibility of using 


PREVENTION 


107 


our knowledge to educate the leaders and the men in this particular 
field of national defense. 

I think that the ship owners and the ship operators need enlight¬ 
enment. I think those licensed officers who are to have the immediate 
supervision of the men’s welfare should have a psychiatrically 
oriented section in their course of instruction, which would give them 
a sense of the particular responsibility they have for playing the role 
of the kind boss, or, if you like, the kind father, for their men, and 
to give them insight into the degree of dependence that their men 
have on their leadership, both for understanding their individual 
functions on the boat, and for appreciating the fact that they are 
being properly looked out for, on the sea and land alike. 

I think the movement that has been started here for the forma¬ 
tion of clubs and rest homes was the first and most essential job for 
us to have done. The next, perhaps, is to find a means for handling 
those whose illness requires a longer period of treatment. 

The partnership of psychiatry with the union is going to be 
perhaps one of the most significant things in the whole affair. Neces¬ 
sarily, the union has come to be the source of support on which the 
men rely for their welfare and for the future programs designed to 
promote that welfare. I remember Dr. Blain telling me in the early 
part of his work that the union leaders were very firm in taking a 
stand: “Now, we are not going to have our men made into guinea 
pigs,” and that when they learned that the interest of the Public 
Health Service and of psychiatrists was the interest of doctors in 
taking care of their men and in doing everything they could to keep 
them well, that was O.K. Now that seems to me to be a very impor¬ 
tant entering wedge into the future relationship of psychiatry with 
the union and that a useful collaboration on the basis of better 
understanding could go a long distance in providing the type of 
emotional security for the men which they need in this very haz¬ 
ardous service. 

Chairman Bowman: Thank you, Dr. Millet! Dr. Millet has 
suggested that to bring up the morale of the seamen, the proper 
training of their officers and the teaching of something in the nature 
of psychiatry to them would be an important step. We have with us 
Dr. Justin Fuller, of the U. S. Public Health Service, who is Medical 
Director of the Training Division of the War Shipping Administra¬ 
tion. I wonder if he might like to discuss that and other topics. 


108 


TRAUMATIC WAR NEUROSES 


Dr. Justin K. Fuller: Thank you, sir. 

As I have listened this morning with extraordinary interest to 
the various themes that have been woven into this discussion, I think 
the theme that resounds with the greatest emphasis is the one that 
attributes marked individuality to the seaman. The seaman is an 
individualist above everything else. This has been recognized a 
dozen times today by a dozen different speakers. The seaman who 
elects to go to sea, who chooses the sea as a career, it has been said, 
does so for a reason. That reason may have different facets to it, 
but it fundamentally stems out of the same thing, usually that he is 
an individualist, that while he is at sea, he finds surcease from some¬ 
thing that is unpleasant; and that he finds it better at sea than any¬ 
where else; and it may well be that in this observation we will find 
a solution to some of the troubles that are characteristic of seamen. 

The “old salt,” the typical merchant seaman, so many of whom 
are at sea today, is that kind of an individual. I thought a few weeks 
back, when the manpower order went into effect, that such individu¬ 
als would no longer be permitted to choose the branch of service they 
preferred, but would be apportioned between the services by some 
sort of rule of thumb, and that the individual would no longer be a 
free agent in the matter. The Merchant Marine would then be re¬ 
cruited in some such fashion as the Army is recruited—one man in 
the Army, one man in the Navy, one man in the Marine Corps, one 
man in the Coast Guard, one man in the Merchant Marine. It hasn’t 
developed in that way, and those men who are planning to go into 
training now select themselves in much the same fashion that seamen 
have selected themselves from time immemorial. So we are still con¬ 
fronted by the fact, by the situation, that the men who go into the 
Merchant Marine choose that profession themselves and still have 
the individuality which has always characterized seamen. Now that 
may be good or bad, it may or may not help the therapeutic problem 
that we have in front of us. 

It may be that our problem is one of selecting the neurotic who 
is best suited, rather than in trying to select men who are free from 
neuroses. 

Colonel Halloran this morning suggested, by inference at least, 
at least to me, that we might call some of these men, some of these 
individualists, constitutional psychopaths. The term “constitutional 
psychopathic inferiority” is a much hackneyed phrase that has for 
many years been in disfavor in certain psychiatric circles, but to me 
it has always described a valid entity. Psychopaths make the best 


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fighters in the world. They have better than average intelligence; 
they don’t profit much by past experience. They are individualists. 
They are brave. And yet they do have this queer mental condition 
which makes them a little different, which sets them a little apart 
from other people, and makes them unpredictable and hence danger¬ 
ous in certain positions. 

If we can find a way to treat the psychopath, so that he will be 
able to control himself sufficiently to stay within the bounds of safety 
for the position which he occupies, I feel certain that we would have 
found the solution to the profitable use of psychopaths and border 
line neurotics and other “individualists” in the Merchant Marine 
and other armed services. 

The Division of Training, it is no secret, is participating in a 
plan to staff some 2,000 ships that are expected to be built this year. 
In all of the eleven units of the Division of Training, there are some 
30,000 seamen in training for the Merchant Marine. Those eleven 
units comprise cadet schools for officers; schools for the training of 
apprentice seamen, of able seamen for officership, and schools for the 
training of seamen, cooks, bakers, radio men, hospital corpsmen, 
engine room men, and so on. 

The average length of training of these men is between three and 
four months, which means that each year we will train somewhere 
between 80,000 and 100,000 men. We realize very definitely that the 
time we have in which to train these men is too short to select them 
as we would like, and to treat as we would like those who have mild 
psychobiological dysfunctions that we feel can be cured or so much 
improved that the man will make a good merchant seaman. Some, 
unfortunately, we have to screen out. But we have been busily work¬ 
ing on plans to salvage borderline cases ever since last October, when 
this probleni was placed in the hands of the Public Health Service. 
We have been training psychobiological teams at each one of these 
training centers. We have been handicapped to a certain extent 
by the difficulty of getting good, satisfactory psychiatrists. We prefer 
to have them on a full-time basis because we think it is a full-time 
job. We have put into every Training Station, almost without ex¬ 
ception, psychologists, and we are adding the psychiatrists as quickly 
as possible. 

Part of the course of training consists of a series of at least half 
a dozen lectures to each class on various appropriate psychobiological 
subjects. We try mainly to put between the trainee and the shock¬ 
ing experiences that he is certainly going to be subjected to, a buffer 


110 


TRAUMATIC WAR NEUROSES 


that will enable him to escape without too serious psychic damage. 

Part of the program—not part of those lectures, but an additional 
medical part of the program—is instruction in first aid and all of its 
implications. Another part of the medical program is the develop¬ 
ment of a so-called pharmacist’s mate service for the Merchant Ma¬ 
rine. The smaller cargo ships of the Merchant Marine have hereto¬ 
fore had nothing at all that in any way resembled the medical service 
on the smaller vessels of the Navy. In peacetime, a destroyer or an 
isolated Marine Corps station has experienced pharmacist’s mates 
who are not graduate doctors but who, to all intents and purposes, 
are very excellent practical doctors. The cargo ship has nothing of 
the sort and we hope that we can develop enough pharmacist’s mates, 
so-called, to put one on each one of the ships during the war and for 
a considerable time during the post-war period. We hope that the 
companies who operate ships will find that there is so much hard 
cash value in this plan that they will continue to employ the pharma¬ 
cist’s mates we are training and that they will ask us to continue to 
train those men in peacetime. 

Incidentally, a pharmacist’s mate on a merchant ship, a non¬ 
passenger carrying ship, is not a total commercial loss to the company, 
because he can act part-time as a supercargo or clerk, thus not neces¬ 
sitating an addition to the number of crewmen. His medical duties 
consist of looking after ship sanitation, the health of the crew, seeing 
that the ship is kept clean, helping her through quarantine pro¬ 
cedures, and so on. It is generally admitted, I think, by hard-headed 
business men, shipping men that I have talked to, that a pharmacist’s 
mate under those circumstances will pay his own way. 

The merchant seamen of today is by no means the forgotten man 
that some people think he is. The Victory ship of today is so far 
distant in its physical attributes for the comfort and benefit of the 
crew from the ships of a few years ago that there is just simply no 
comparison. The modern ship in the last few years, and especially 
the Victory ship, has good sanitation, and refrigeration. The food 
rarely, if ever, spoils any more. The seaman is, comparatively at 
least, away and above what he had to endure a few years ago. The 
seaman of today is no longer the helpless individual that he was even 
a few months ago. 

The training courses at the Division Training Stations include 
gunnery. Each seaman learns his part in manning a 5-inch rifle, anti¬ 
aircraft rifles, and small arms. The gun crews are welded together 


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by an esprit-de-corps that the old Merchant Marine did not know 
at all. 

Finally, the last point that I wish to make is that the merchant 
seaman is no longer the casual individual that he once was. The 
merchant seaman of today on American flag vessels is being educated 
into the benefits of being in a uniformed service. The standards of 
physical and mental aptitude that we demand in selecting men for 
training are now on a par with those for enlistment in the Navy. We 
feel that the merchant seaman should be as dependable a person as 
anyone in the world, because he is for longer periods of time isolated 
with a smaller group of officers than in almost any other military or 
semi-military occupation. We no longer can select merchant seamen 
in the careless way that they were once selected. We no longer can 
condone the orgies that are usually associated with a seaport and a 
seaman just getting off his ship. And a large part of the reason for 
that is that the seaman of today will wear a uniform and he must 
honor that uniform. Thank you! 

Chairman Bowman: I believe that Dr. Karl Menninger was 
telling us this morning about his almost traumatic experiences in 
flying around overhead trying to get down and not getting here quite 
in time; but he also had something of a story about some captain 
that he was going to tell us about, and he will tell us about that now. 

Dr. Karl Menninger: I sometimes think psychiatrists are so 
preoccupied with why men fail that we are not sufficiently interested 
in the study of prevention. In addition to what can be learned from 
those failures in morale, those instances in which circumstances have 
overwhelmed individuals, we might also consider scientifically, if we 
can, some of those less familiar instances in which circumstances 
overwhelm the individual. 

In the course of some extracurricular peregrinations, I was in¬ 
vited one evening to a little party at the home of a man who had just 
published a book. I found the guests to be largely Scandinavian 
men and their wives who were interested in Scandinavian folk songs; 
I was interested in that, but I asked the host how he, a sea captain 
and author, came to be so especiallyjnterested in that. “Well, he 
said, “you see, a good many of my boys are Swedes and Norwegians 

and these are some of my boys.” 

“But you are not Scandinavian, I said, 




112 


TRAUMATIC WAR NEUROSES 


“Oh no,” he said, “I am a Scotchman, or I was? I am an Ameri¬ 
can now.” 

I was rather impressed by that to begin with, and then talking 
with him, I was struck by some paintings on the wall and I asked him 
about them, and he said, “Oh, I do those on some of my trips.” 

I said, “I thought you were an author.” 

He said, “Oh, I write those books when times are duller.” 

“Aboard ship?” 

“No,” he said, “usually in port, because I am too busy aboard 
ship.” 

Well, I thought that>was enough evidence that that was a success¬ 
ful man and I wanted to know more about him, so I talked with 
him quite a long time. I even persuaded him to take a Rorschach 
test. I have known him socially since that time quite well and I 
won’t tell you all about him, but I want to tell you a few things about 
him. 

In the first place, he sails a merchant ship back and forth without 
a convoy all the time, right now, and I think there have been several 
accidents but none of them too serious; his ship has never been sunk. 
But I do know, or I am almost sure, that none of his sailors has 
been a patient in any of this work yet. I don’t know all the 
reasons why, but I will tell you a few of them. 

For one thing, these sailors will not sail with any other captain 
under any circumstances. They think that he is just simply next to 
God. How he accomplishes this, it seems to me, might be worth very 
careful study for more general purposes. I will just give you a few 
little vignettes. I can’t tell you all of it. 

He was telling me about one crossing recently in which there 
was a very severe gale. In fact, it blew one of the sailors overboard, 
an old-timer; it was that bad. He told me he thought the ship might 
founder, which is rather rare, and something he had never experi¬ 
enced, but he was pretty worried. The storm was accompanied 
by frost, ice, sleet and so on. It was so bad he had mid-Western 
boys who had never been to sea before the present war manning 
these guns. He sent a sailor out on deck to tell these fellows to 
abandon their guns, that no submarine or anybody else could 
survive in weather like that, and for them to get below deck. The 
sailor attempted to go up and the wind was so strong and the sea so 
rough that he couldn’t get to the men. He didn’t tell the captain 
this. 

The next morning, the wind had abated somewhat and the cap- 



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tain went on deck and he found these boys with their arms locked 
around the guns lying prone on the deck covered with sleet, their 
clothes stiff as boards. They were still hanging to the guns. He said, 
“Well, how did this happen? Are you fellows alive?” 

They said, “Yes, sir; we are all' right.” 

He said, “Well, I sent word for you boys to go below last night.” 

They said, “Well, we didn’t get it, but that is all right, sir. We 
stuck it out.” 

He said, “Well, you might have frozen to death. You might have 
been washed overboard. Don’t do it again. You should have aban¬ 
doned your guns” 

“Oh no, sir,” they said, “you wouldn’t have approved of that 
really.” 

I don’t know all he said, but, at any rate, he said, “Well, go 
below now anyway and get fixed up.” 

I mention that as an indication of - the kind of discipline he 
maintains. He said it was absolutely absurd for them to stay there; 
he wouldn’t have reproached them if they had gone down below, 
and in fact he thought they had gone and he reproached himself 
because he might have been the cause of their death. 

That is one instance. 

I said, “Well, did you have any shock of one kind or other?” 

“Oh, yes,” he said, “sometimes.” 

I said, “You have no doctor aboard?” 

“Oh, no.” 

“Who treats the men?” 

“I do.” 

“How,” I asked. 

“Feed them,” he said, “just feed them; that’s a good treatment for 
lots of things.’’ 

I said, “Your boys get to London and New York; is there a little 
venereal disease acquired?” 

“Oh, yes,” he said, “sometimes.’’ 

“Well,” I said, “you don’t discover it until they get back on 
board. Who treats that?” 

He said, “I do.’’ 

I said, “You treat both gonorrhea and syphillis?’’ 

“Oh, yes,” he said, “I have to; there is nobody else.” 

So I began to think what a sailor he must be to be able to do 
everything. 


114 


TRAUMATIC WAR NEUROSES 


He said, “That is nothing. We all do that. We have to know a 
lot of things aside from running a ship.” 

“Well,” I said, “who takes over the boat when you sleep?” 

He said, “I don’t sleep.” (Laughter) 

I said, “Well, you rest a little?” 

“Oh,” he said, “four hours a night I do. The mate takes over.” 

I said, “But you hardly get undressed in four hours and dressed 
again.” 

“Why no,” he said, “the captain doesn’t undress and dress aboard 
ship; you know that, don’t you?” 

I said, “Well, some of them do. Maybe you don’t.” 

This may sound a little incredible now, but I believe it is 
credible. 

Now, what are the features of that leadership which so inspire 
these men, which give them such complete confidence in him that 
nothing shakes their morale? 

I am confident—of course, this is only a hypothesis— that any 
external events, I mean the ordinary external events which over¬ 
whelm men, would leave most of his men untouched, because it ^ 
seems to me what I missed in some of the discussion of the etiology 
today is the question of the relation to their captains of the men 
who were so overwhelmed by these external events. I think this 
should be stressed because of what several people have said about the 
character, not just of men who go down to the sea in ships, but of 
the men in the merchant fleet particularly. My impression, from 
what has been said here and from one of these sailors who is now a 
physician, and has been psychoanalyzed, and whom I know well,.is 
that the attachment of many of these men to home figures is relatively 
less than that of a good many other sailors, and soldiers, and their 
attachment to one another and to their captains is for that reason all 
the greater. 

There might be, it seems to me, an opportunity to study morale 
in pure culture on such a ship as I described, run by my friend the 
brave captain, and it might be exceedingly important to know what 
the deeper personality structure of such a captain is, because pre¬ 
vention is so much better than cure., 

It seems to me that in all our thinking about this problem, we 
haven’t given enough consideration to the nature of the man who, 
after all, becomes the little Napoleon, the little god, of this 50 or 
150 to 250 men with whom he lives so intimately for days and days 
and days, surrendering all other human bonds excepting those in 


PREVENTION 


115 


this artificial but certainly not unusual human constellation in which 
morale may be very high—or very low. 

This, it seems to me, as Dr. Millet said, is an educational func¬ 
tion of psychiatry. Where is there an area of investigation for psychi¬ 
atry concerning success? Such an area might prove to be a welcome 
relief after our consistent investigations of failures. 

Chairman Bowman: We are interested in experiences in fields 
related to that of the Merchant Marine, experiences whereby we can 
learn something about the cause, the prevention, and the treatment 
of these early war neuroses. I am going to call on Dr. Parsons, who 
was Commanding Officer of Base Hospital 117 in France during the 
last World War, to tell us anything he wishes about his experience in 
the treatment of acute war neuroses and in their prevention that 
would fit into our program here. 

Dr. Frederick W. Parsons: Mr. Chairman, Ladies and Gentle¬ 
men: I was delighted when I was asked to become a member of the 
New York Committee of the United Seamen’s Service and duly ap¬ 
preciate the honor of being invited to this meeting. I long have had 
an interest in sailors and ships so I found myself in a congenial atmos¬ 
phere in the Andrew Furuseth Club. The men of the Merchant 
Marine are doing war work of a particularly hazardous nature. Some 
break, but under the direction of the United States Public Health 
Service physicians (if available, and they cannot have representation 
in every port) the sick and maimed get excellent care. A few have 
nervous symptoms and Surgeon General Parran has asked this dis¬ 
tinguished group of service and civilian physicians to confer, and if 
possible to suggest further steps to be taken. 

I am asked to speak on the question of prevention. It is difficult 
to know what to do with these men who travel to distant points and, 
until they get sick, rarely see a physician. I expect the officers know 
who is breaking but they are literally at sea, the daily work has to 
go on, and I judge the officers can do little for threatened nervous 
breakdowns. 

Our Merchant Marine has been prominently in the public eye 
only since the beginning of the war. Prior thereto it constituted a 
group of men about which the man in the street knew little and cared 
less. I expect many of the ship’s men felt that way about the men 
ashore. Now the sailor knows he has friends and we landsmen know 
more about the deep water men. 

The influence of the officers seems important. I was dining out 


116 


TRAUMATIC WAR NEUROSES 


a few weeks ago and an American naval officer came in, a captain 
with three of four of his junior officers. I looked at that man and 
I said, “Mister, I’ll go to sea with you or anywhere else.” 

He had a radiant personality, cool, calm and collected. There 
was ability written all over him. I think with Dr. Menninger that 
the men who sail with that man will rarely break down. 

Nothing has been said today at all about war nerves among the 
officers. What happens to them? Do they break down? Where do 
they go if they develop nerves? Upon whom do they lean if they do 
have a breakdown? Subsequently in the discussion I shall be very 
glad if somebody who knows more about the whole question than I 
do will have something to say about what happens to the officers when 
their ship is torpedoed. They are exposed to the same hazards which 
cause breakdowns among the seamen. 

I do not take too seriously the psychoneuroses among the seamen. 
Except for those who have been neurotic for years, the symptoms are 
• not so deeply seated as those we were accustomed to see in the Army. 
Those whom I have seen at Gladstone and at Oyster Bay delight a 
physician by their response. As has been said, they have no incentive 
to hold on to a nervous disorder. They are sailors. They want to go 
to sea. Ashore they are unhappy, and out of pocket too. When one 
can do what one wants and get paid for it, why hang on to a 
psychoneurosis? 

Chairman Bowman: We have in this country one organization 
which is noted for its educational work in the prevention of mental 
disease, so I am going to call on Dr. George S. Stevenson, of the 
National Committee for Mental Hygiene, to give us any ideas which 
he feels pertinent 

Dr. George S. Stevenson: My tendency would be to look for 
leads among the reactions of persons in ordinary civilian life. We 
were shown three cases this morning. In all three there was a re¬ 
action of embarrassment at speaking before a group of doctors. It 
wasn’t war nerves this time; it was rather nerves brought about by 
the newness of speaking before a large group. They had not been 
hardened to this particular situation, hardened in the way that Dr. 
Rado had suggested the hardening might take place in relation to 
maritime situations. Now, of course we don’t think of their embar¬ 
rassment as a neurosis, at least not the sort of neurosis that we worry 
about. The situation is not new. It was described long ago by 
Longfellow. Miles Standish, a hardened soldier, had to get some- 


PREVENTION 


117 


body else to speak for him because he faced a situation with which 
he had not had experience. 

Dr. Baker has given us some very practical suggestions for 
strengthening the man for new experience. 

In civilian life all persons have gone through a progressive hard- 
ening process, not the specific hardening process for the Merchant 
Marine, but a hardening process that allows them to meet the circum¬ 
stances of life. The school boys of today are practicing at war play 
to meet some of the actual war situations they may be having to take 
seriously in two or three years. 

In getting a better understanding of the physiological concom- 
mitants I think also of Wingate Todd, who had his medical students 
learn visceral anatomy on each other by use of the fluoroscope. In 
that process he discovered that the normal anxieties of the first year 
medical student were rjeflected in changes of tone in the stomach. As 
the hardening process went on and they became sophomores, the 
stomach became a different organ. He had in this a concrete 
example of what actually takes place viscerally in the hardening 
process. By contrast, he occasionally found sophomores with fresh¬ 
men’s stomachs and was able to demonstrate that in those cases the 
anxiety didn’t come from the newness of the situation but from 
something more akin to a neurosis. 

Chairman Bowman: Dr. Meyer, I think as president of the 
National Committee for Mental Hygiene, you should also discuss a 
little bit the preventive work for mental health. Give us your view. 

Dr. Adolph Meyer: I have been strongly reminded throughout 
this day of the man who has probably done most to start, in practice 
as well as in theory and in spirit, preparing the ground for psychiatry 
for World War I—I mean Thomas W. Salmon, who was inspired very 
largely by his experience with the deep sea fishermen, after all a 
group that also comes very close to those of whom we are speaking at 
this session. The contact he had with that set of people led him 
particularly to be concerned with what personal development can 
do and undo. 

We have spoken to such an extent of the inspirational part of 
this whole field that perhaps we would do well to bring it somewhat 
into connection with the more theoretical, if you want to call it so, 
necessities that we have had to meet. 

I was very much interested this morning in the fact that three 


118 


TRAUMATIC WAR NEUROSES 


patients were brought in, that they were allowed to give us the sense 
of reality of what we had to discuss, an element of demonstration of 
what kind of facts they offer. Evidently our task in that sort of 
thing becomes very practical. It demonstrated that we are dealing 
with what in general is the problem of psychiatry: a call for plain 
sense in dealing with human problems, helped by clearer and clearer 
willingness to see and guide the accessible facts. 

Psychiatry is very largely that part of medicine, or that part of 
practice and good sense in dealing with patients, which is concerned 
with the account of various usual first consequences, but also modes 
of development and also the yearning for correction in matters 
brought before us as examples at the start of this meeting. 

Our problem in psychiatry is really that of forgetting terms and 
the quibbling about them, and more that of presentation of data 
of experiences, a presentation of demands, and passing on to a means 
of doing justice wherever and howsoever the demands can be effec¬ 
tively reachd. 

The regular definition that I usually give of pathology would be 
more or less in line, i.e., seeing what works; what does not work so 
well, and why; and, finally, what does not work at all. That is the 
definition of the perspectives in the concept of pathology and thera¬ 
py. Evidently we are dealing with something in which also the prob¬ 
lem of morale has been emphasized. I could not want a better term 
or better concept for that whole problem than that of “morale” in its 
best definition. A great deal has been said about it. We might like 
to look for something that like a chemical, could be bought and 
handed out. Obviously, it is the balance of security and insecurity, 
the problem of things that work and things that do not work. 

Our purpose is to obtain information, knowing what the goal is 
for which one heads, whether it is in the Merchant Marine or in any 
sort of pursuit that has equal hazards, equal dangers. 

So this question that we are confronted with is one of loss of 
security, partly through situation, partly through inadequacy of 
preparation, lack of hardening process, as Dr. Stevenson mentioned, 
and then the restoration of the perspective, the conditions under 
which that sort of restoration is possible, the problem of sleep, the 
problem of recreation, and a vision of hopes to be active again and 
for what. 

Personally, I have not had any experience in any condensed form 
with some of the things that many of you actually have had. Some 
of you have had experience as psychiatrists in the first war. By reason 


PREVENTION 


119 


of various circumstances, I had some experience only in giving some 
help in training, but I always bring it into connection very largely 
with that which we have to meet when we see patients not for pro¬ 
tracted treatment, where we can leave things more or less just to a 
question as to whether a patient shall or shall not go into a hospital, 
but where we have, perhaps in one session or a couple of sessions, to 
form an idea of how that which the patient brings to us can be dem¬ 
onstrated in terms of a mode of living, terms of a mode of orienta¬ 
tion, of adjustment. That is what psychiatry really is doing. It has 
to determine what belongs to the person’s function, what are the 
hazards from the use and abuse of organs, and remedies of that sort 
that have come to include rather high-handed procedures to the 
point of coma and convulsions. 

Now there is more and more of an idea of this in the public mind, 
and we ought not, therefore, to get into that channel which prevails 
very largely in the English circles, where they make a tremendous 
distinction between psychosis and psychoneurosis, and evidently very 
much at the expense of the psychosis. Psychoses are, after all, things 
that can happen in many forms and are not always what the public 
thinks them. We have to teach people that when we speak of 
psychoses, we speak of things that are very close to the status of “the 
person.” There are a good many features involved that we carry as 
we do a “physical” disease. Those things, evidently, to which all that 
we call morale applies, that the individual has to meet with prompt¬ 
ness of choice also under circumstances of disaster. That is what one 
also has to get hardened to and intelligent about, and to be able to 
face and to treat not so much as a matter of horror, but as a matter 
that requires preparedness of conduct, of vision, of endurance. Those 
are among the things which, as it were, are largely the upshot of what 
I mean by morale: the respect for the personal aspects among persons 
and the respect for health, respect for the coordination of that which 
is human, one’s mental attitude, one’s necessity of looking forward, 
looking backward, and then the means of handling it, waking and 
asleep. 

Sleep means a great deal as a paucity of function. It probably 
shows in these conditions about as strongly as almost anything that 
has been mentioned in the symptomatology and in the problem of 
treatment. It is a most fundamental form of an action of reconcen¬ 
tration, you might call it, and of distraction, followed by re¬ 
immersion into the necessities; and the transition states are the ones 
in which the weeds show as well as the good fruits and the chances 


f 


120 TRAUMATIC WAR NEUROSES 

for new gains. I think that has been made very clear in the dis¬ 
cussion, together with the handling of the situational uncertainties. 

It is a great pleasure to see a particularly concentrated type of 
vital pursuit and vital emergencies emerge in the text of our discus¬ 
sions, and it is exceedingly interesting to see that at present we still 
have relatively few opportunities for training and familiarization. 
What Dr. Hoffman has given us as a picture of his hospital is only 
to a relatively small extent devoted to a retreat for war victims, but 
actually offers the nucleus for provisions for the shaping of policies 
and morale. Most interesting perspectives are brought up in those 
subjects that Dr. Blain has given us a demonstration of, with material 
for such a simple program that I would recommend it for all con¬ 
ceptions of psychiatry. There is the story of the patient; learn to 
translate it into terms in which you can use all the training and sense 
of your scientific acumen, and then translate it further into life, and 
therapy, and part of the morale concerning certain lines of occupa¬ 
tion, and you will in that way get a good idea of that which you still 
call psychiatry, but which we do not want again to make a matter 
of designation of the abhorrent and mere segregation and elimina¬ 
tion, but more and more a matter of morale and of health and help¬ 
fulness in life. 

Chairman Bowman: We have with us from Canada, Lieutenant 
Wellman, of the Royal Canadian Navy Medical Corps, who is chief 
psychiatrist of the Navy Yard at Halifax. I am going to ask him if 
he will say a few words. 

Dr. Marvin Wellman: Sir and Gentlemen: My experience with 
this illness has been with fighting men, chiefly Canadian seamen. I 
am convinced that any personality, if exposed to sufficient trauma, 
will develop such a reaction. Of the cases seen by myself, 673 to 
date, I would only have considered 37% as abnormal before the on¬ 
set of the present illness. Conclusions as to primary instability de¬ 
pends, of course, on the criteria of the observer. 

At the Royal Canadian Naval Hospital, Halifax, the importance 
of early treatment is stressed. The patients are made to realize that 
this is a way the body has of acting and that it is not something which 
will take them from the service. The war is still to be fought and 
they are going back to do their share. Less than 10% are discharged 
from the service. The remainder are treated and returned to full 
duty. 

I wish to express the regret of the Surgeon Captain at not being 


PREVENTION 


121 


able to attend this meeting as he was detained by other duties in 
Ottawa. 

Chairman Bowman: I am going to ask Dr. Carl Michel, Medi¬ 
cal Director of the Coast Guard, if he cares to discuss this. 

Dr. Carl Michel: Mr. President, I have been sitting listening 
and a great many facts were brought out, but to make the proper 
recommendation the best way, of course, is to draw on experience. 
Since we are dealing with seamen, certain facts that have been 
brought out seem to be applicable to several incidents I have ob¬ 
served with respect to torpedoed seamen. In the Spring, considerable 
torpedoing was going on down the Florida Coast and I happened to 
pass by there. One day 400 American and foreign seamen were 
landed from torpedoed ships. I looked them over; they were all 
happy, were glad to get ashore and the first thing they were interested 
in was getting plenty of food. They were all hungry. Well, a while 
later a ship was torpedoed, a British tanker coming over, and the 
tugs managed to get hold of her, the torpedo having gone through 
the engine room. I got out on the tug and got on board the ship. 
So I observed the behavior of the captain and the crew, just what they 
were doing. There had been two men on watch and they were totally 
disintegrated. You couldn’t find anything of them. Then I went 
to speak to the captain, an Englishman, weighing about 250 pounds, 
and he had a bottle of beer in his hand and he began to talk to me 
about the event. He said, “The first thing I knew when the ship was 
torpedoed, I got the men to work,’’ and sure enough, all the men were 
hard at work cleaning up, v;orking just as hard as ever, and they wefe 
cursing roundly. That was about the only reaction I noticed. 

Now, all this is applicable to Dr. Menninger’s captain. Apparent¬ 
ly this master had absolute control of his men and the first thing he 
thought of was keeping them busy so they couldn’t think of anything. 
Naturally they had found an outlet—they were cursing. But none 
of them went back to the engine room where the disaster occurred. 
They w^ere working hard cleaning up the ship. The first thing they 
wanted to know was when they could get to port and get a cargo so 
they could go back home. That is about all. 

I certainly liave enjoyed the meeting. There are so many facts 
that have been brought out, I think with marked success, that the 
future prevention of neurosis among seamen should be cleared up 
in a short time. 


122 


TRAUMATIC WAR NEUROSES 


Chairman Bowman: Dr. Foster Kennedy, would you care to say 
something? 

Dr. Foster Kennedy: Gentlemen, I came away from the last war 
with the absolute knowledge that the morale, the emotional tone of 
a regiment, depends more on two officers than on any other one thing 
—the colonel and the doctor. The colonel and the doctor can set the 
tone, the emotional tone, of 1000 men. The doctor is the liaison 
officer of the colonel. He has to know all the men, and as many as 
possible of them by name. He censors their letters. He must know 
them in an intimate way that the other officers cannot achieve. He 
must look after them when they are not in action. If he does his 
job well, and knows his men and looks after them, they will not 
break down when trouble comes, if they really trust him. 

He must also go on occasion, wherever other combat officers 
go. He must go over the top with his men. If they respect him, the 
men will not panic under any situation. 

So I suppose it is the same at sea. The captain sets the tune and 
the doctor plays it; and if these two officers work together and are 
fighting men themselves, the tone of the men will be sound and men 
will go back to be fighting men again. 

The doctor, I think, has to be told also in his training that his 
job is a preventive one. He must spot a man going sour. He must 
detect a man who is sitting apart, whose attitude is one of dejection, 
who has lost the fire in his face, who has begun to brood. He must 
pick that fellow up and go and see him, see what is the matter, take 
him out of line, take him out of work, if necessary, or give him more 
work. The officer who spoke last had the right idea of it, that noth¬ 
ing takes up excessive adrenalin like work. The doctor has a pre¬ 
ventive job in the psychoneuroses on land and at sea. We are told 
too much, I think, about how to cure and too little about how to 
prevent. If the doctor is a man himself, the men around him will 
also be men. 

Chairman Bowman: I am going to call next on Dr. Rade- 
macher, of the Public Health Service, who is a psychiatrist, I believe, 
at Sheepshead Bay Maritime Training School. 

Dr. Everett S. Rademacher: Our job as psychiatrists in the 
training station is, like that of Dr. Felix, more of selecting and pick¬ 
ing out of men rather than the actual treatment of shocked seamen. 


PREVENTION 


125 


This morning there was some question as to whether there might 
be certain differences in the nature of the men volunteering for 
service as contrasted with those of the Selective Service group. 
There is perhaps very little difference in many respects. One finds 
that many men volunteering for Coast Guard or Maritime Service 
had rather false ideas as to the true nature of these services. Within 
a few days of their enrollment they discover what they have let them¬ 
selves in for and the result is a shock to them. This shock appears 
often in the form of a sustained fear reaction, comparable to the clini¬ 
cal states we are discussino^. 

One speaker brought out the fact that there were many service 
men who had difficulty in adjusting to service and whose history 
tended to show that as little children their play activity was more 
destructive in nature. I think that we can carry this further and 
show many traits of adolescent behavior which can be used as an 
index to success in adjusting to any service. 

For example, there are many individuals whom we see after only 
two or three days on the station. They have thrown out a knee cap 
or injured a back, etc. Invariably they add that this is the same 
thing that happened when they wanted to play football or some other 
sport. With martyred attitude they declaim their ill fortune that 
these things should happen right at these times. These so-called 
“football heroes of a day” show a need for further study and as more 
is discovered about this form of reaction, a better screening takes 
place. 

The more we realize the importance of earlier personality diffi¬ 
culties and neurotic disturbances, the fewer breaks of a “nervous" 
nature will be in evidence as a result of military service. ^ 

Chairman Bowman: At this point, I am going to ask Dr. Over- 
holser if he will take the chair for the next half hour, because Dr. 
Parran has asked me to go outside. 

Dr. Overholser will take over the chair and the meeting will con¬ 
tinue until five-thirty. There are one or two people I have asked 
him to call on and then the meeting will be thrown open to the 
general discussion. 

(Dr. Winfred Overholser assumed the chair.) 

Chairman Overholser: Dr. Titus Harris, consultant of the 
Marine Hospital at Galveston, Texas. May we hear from you? 

Dr. Titus Harris: Dr. Overholser, I don’t think that I could 


124 


TRAUMATIC WAR NEUROSES 


say anything that would contribute to this meeting. I have enjoyed 
hearing the various discussions very much. Certainly the various 
discussants have said a lot which will contribute to our information 
about the prevention of these war nerve conditions. 

Since I have received the announcement of this meeting and an 
invitation to attend, I have been thinking of the possibility of estab* 
lishing one of the convalescent homes in Galveston, in that it is a 
rather important Gulf port and also because we have a medical school 
and the State Psychopathic Hospital there, which would enable us 
to furnish ample medical personnel—that is, if Dr. Blain thinks that 
there is a need for one in that part of the country. Dr. Blain has told 
me that he plans to visit Galveston and investigate this question. 

To me the meeting has certainly been a success. 

Chairman Overholser: I would like to hear from Dr. Macfie 
Campbell. 

Dr. C. Macfie Campbell: Out of twenty-one merchant seamen 
that have come into the Boston Psychopathic Hospital in the last 
year thirteen were suffering from alcoholic psychoses. So I was inter¬ 
ested to find this forenoon no reference made to alcohol. As Dr. 
Kubie remarked, the seaman is somewhat of a solitary individual, 
free from the ordinary social bonds, attaching himself to small groups 
on board ships, and when in port exposed to a more unfortunate 
environment than any other group that I know of. I suppose the 
environment is improving. 

With regard to the total situation, the difficulty is how to reach 
the individual. With the Army you have a very large, highly or¬ 
ganized system. In peacetime, if you are dealing with the working¬ 
man, you have very large aggregations in industry. If you see 
factors that might be of importance to the welfare of the individual, 
you have already an organization where you can introduce beneficial 
measures; the relation, for instance, of the foreman or of management 
in general to the industrial worker is often open to modification. 
The reaction of the average workman with a repetitive task to his 
situation in one case may be resentment and labor unrest; with a 
different morale or atmosphere it may not lead to any trouble. But 
when you take the situation of the merchant seaman, you find he 
works in very small units; he is an individualist and works in a very 
small group which may be conducive to acclimatization but also to 
paranoia. In connection with the Challenger oceanographic survey, 



PREVENTION 


125 




Sir John Murray said that after they had been to sea about six or 
eight weeks, members of the expedition were barely on speaking 
terms with each other. When they put in to port all scattered and 
got new experiences; when they came back to the ship, they were all 
very good friends again. 

So here you have these units, small groups of these individualists, 
and the captain in a position of very great importance. In trouble, 
the first thing I believe the deckhand does—on a small ship anyway— 
is to look to the bridge and see how the lieutenant, or whoever is in 
charge, reacts. As Dr. Menninger remarks, the captain of the ship 
is the man who has to deal continually with emergencies. He has 
even to set a bone if it is broken. He has to give medicine. If the 
shaft of the propeller goes, he may have to go down and help the 
engineer straighten things out. In the Merchant Marine as in the 
senior service they are always fighting, always fighting against the 
elements and having to make very serious decisions. 

I think it very difficult to see how you can introduce preventive 
measures that can touch the individual seaman through any group 
influence except through the unions and perhaps such organizations 
as the Seamen’s Institutes. 

With regard to the officers, they might get some such insight into 
human needs as it is possible to give management and foremen in 
industry. The first medical contact may take place when the man 
has broken down. I think the most strategical position is held by 
the Marine Hospital when the seaman goes for a systematic review. 

That first contact is of extraordinary importance, I think, because 
with the right sort of attitude the temporary conditions of the men 
may be very judiciously and rapidly dealt with. Under different 
auspices, the seaman may fail to get a wholesome outlook and per¬ 
spective, and may come to the rest home predisposed to prolonged 
invalidism. Very close cooperation between the Marine Hospital 
and the rest home is desirable, as between a rehabilitation center and 
any other hospital. In the organization of the rest home, perhaps 
the unions and Seamen’s Institutes might have valuable suggestions 
in relation to the speedy rehabilitation of the seamen. ^ 

Chairman Overholser: Dr. Rado, may we hear from you? 

Dr. Rado: Obviously, prevention is a most important aspect of 
our problems. I should like to call attention to the fact that pre¬ 
vention is possible and necessary in three successive lines, and that 


126 


TRAUMATIC WAR NEUROSES 


in each of these lines we are facing somewhat different problems. The 
first line of prevention is to prevent acute reactions from occurring. 
If this fails and an acute reaction develops under treatment, the 
second line of prevention is to prevent relapse. This is the true cri¬ 
terion of the efficaciousness of every treatment from the military 
point of view, and here also from the point of view of service a man 
is only cured if he is returned to full service, and that implies that he 
is now considered safe from relapse. 

The third line of prevention is to keep a man with an acute con¬ 
dition, whom we can no longer return to full service, from deteri¬ 
orating further, and from developing an organized fear of combat 
and war and turning into that classic picture of traumatic neurosis, a 
man who will be lost not only for the services but also for society. 

The task of all of these three lines, therefore, is different. Problem 
No. 1 has been very ably discussed by Dr. Baker. It is a problem of 
morale, but we discussed this morning, in addition, a problem of in¬ 
doctrinating a proper technique as to how the man should resolve 
both the situation and himself. The problem can be stated in one 
sentence. The situation touches off the most elementary human emo¬ 
tions—fear and blind rage. If the man spurred by morale permits 
these emotions to arise and then, spurred by morale, tries to repress 
them, he is licked. His problem is to prevent these emotions from 
rising at all. 

The technique I am talking about shows that it can be done. A 
very simple experience is illustrative. We all remember in medical 
school when we first saw the inside of a dead human being, the 
reaction of fear, revulsion and disgust. That gradually disappeared 
and was completely replaced by a technical reaction. You saw only 
the medical structures, and there was no intrusion of human emo¬ 
tions any more. 

Now, the whole problem in combat is to keep your mind and 
body busy in a technical and rational way. If your body and mind 
are permitted to be idle, then it is almost inevitable that those 
emotions which hold sway will begin to turn your mind on this 
human way of looking at the situation; you begin to develop fantasies 
such as, “How can I get out?” 

It was reported this morning that idleness is a great danger. Now, 
in the Merchant Marine the situation is particularly difficult. The 
men who have a gun feel better. They can be busy with the gun. 
I saw in January of last year a British sailor who went through the 
“blitz” in Coventry and I was delighted and amazed to hear this 



PREVENTION 


127 


man relate his experience. We had a group for the study of these 
conditions. He was invited to talk, a simple guy, an ordinary sail¬ 
or. He said, “The man who keeps busy and the men who are able 
to take responsibility for others are safe. The men who are kept 
idle are in a terrible condition.” 

Now, this is the essence of that whole situation. How can that 
be solved in the Merchant Marine where there is this inability to 
shoot back, to do anything? It is a very ticklish problem. 

I should like to say a few words, if it is not too late, about the 
beautiful study of Dr. Menninger. There can be no doubt about it 
that you can build magnificent morale on attaching yourself in a 
semi-religious way to a leader. This is a powerful prevention, but 
a psychological setup with frightful dangers. Did it occur to you to 
ask what happens if this captain dies? Now I will answer that ques¬ 
tion. I had the opportunity in Captain Marsteller’s hospital in 
Bethesda to see a Marine major who was second in command under 
a lieutenant colonel in the Guadalcanal area. This man’s mind cen¬ 
tered around the problem of what was going to happen to him if 
the lieutenant colonel died. If it was reported that Japanese snipers 
were here and there, he would say, “Come boys, let’s get them.” He 
went everywhere and over-exposed himself and it drove him into 
Bethesda Hospital. That may come from such an attachment. 

I believe that in addition to organization and discipline, the man 
must be able to stand on his own feet, and all war experience brings 
out more and more the increasing significance of this point. These 
two principles are opposed. Therefore, we can not go very far in 
that direction. 

Now, as to the prevention of relapse and of traumatic neurosis 
proper, I would just limit myself to one thing. Once there is an emo¬ 
tional, an over-emotional state induced, and the individual tries to 
suppress those emotions, the minute you permit in his conscious 
mind the idea to take form, “Let me get away,”—and that idea is 
certainly forced there by all such things as giving him a diagnosis, 
telling him that he is sick—you don’t do him any good. 

Therefore, the point I wish to make here is that I heartily wel¬ 
come all these measure that have been taken in this organization to 
eliminate the introduction of ideas that feed the anxiety of the man. 
I am not afraid of camouflaged psychiatry; we are dealing here with 
a practical problem and everything that is suitable must-be done. 

Chairman Overholser: Gentlemen, there are about fifteen 


128 


TRAUMATIC WAR NEUROSES 


minutes left before the scheduled time of closing. There are several 
men who have not been heard from who I know could add a good 
deal, if they will. I won’t embarrass them by calling on them, but 
there are fifteen minutes available. We would be glad to hear from 
any of them. 

Dr. Leslie H. Farber: My experience has been similar to that 
of Dr. Hoffman, who mentioned the very small percentage of trau¬ 
matic neurosis at the hospital in Nova Scotia. Since I have been at 
the Norfolk Marine Hospital I have not seen or heard of a single case 
among merchant seamen, although I have seen two or three cases 
from the Coast Guard. Before I came to the hospital, 200 torpedo 
survivors had been brought in directly from the lifeboats, and I was 
surprised to learn that none of the medical or surgical men had seen 
any traumatic neurosis among them. It may be that a few cases were 
missed for lack of psychiatric training, but I would guess that the 
incidence, if any, was remarkably low. 

At present we have between 50 and 100 merchant seamen there 
all the time, at least half of whom have been torpedoed at one time 
or another, and I am amazed at how little psychological disturbance 
among them can be directly attributed to the war. I think the rea¬ 
son lies not only in the merchant seaman’s personality, but also in tfie 
special conditions of the maritime service which permit an unusual 
degree of personal freedom. If a seaman dislikes his captain or his 
ship, he can transfer to another for the next trip, and he is not forced 
to accept the first ship that is offered to him. I think this all helps to 
insulate the merchant seaman from neurotic disaster. 

In this connection, I must disagree with Dr. Hoffman’s suggestion 
that each seaman should stay with one crew for the duration. That 
would be almost fatal for many of the men I have seen. They need 
that individuality and independence—the rebellion that is a charac¬ 
teristic of their trade and their personality. 

Dr. Felix Deutsch: I should be immodest if I were to take your 
time for ten or fifteen minutes to make remarks of my own. But I 
was impressed by many things that the speakers said. If my memory 
is faithful, I remember that they were paraphrasing much of the book 
of Freud on group psychology, and all that has been said here in the 
last few minutes is written there. The Army and Navy is an artificial 
group, held together by a relationship of a father and the brothers. 
This relationship is the basis for as well as the means of preventing 


PREVENTION 


129 


breakdown. So indicated Freud, very carefully as was his wont in 
this book, which I highly recommend that you read, because it will 
give a good basis for further thinking. 

Chairman Overholser: Is there any further discussion? 

Dr. John A. P. Millet: I arise to a point of information. Very 
little has been said about the expected disposition of those cases which 
have been found unsuited for further service, either because of unex¬ 
pected relapses or because the nature of their disability on the first 
attack seemed to prove that they were unlikely to succeed in further 
service. It seems to me that we have here a tremendous problem in 
rehabilitation. I am wondering what plans have been made by the 
Public Health Service to cover this problem, which should be faced 
along with the rehabilitation of people who are physically injured. 

Dr. Vernon Williams: I should like to ask a question, or per¬ 
haps make a suggestion, in regard to the treatment in these rest homes 
of which we heard. According to the memorandum which we have, 
the individual patient is given forty-five to sixty minutes in which his 
history and first interview take place. After that, about three ten- 
minute private interviews a week are given. Now, perhaps I mis¬ 
understand, but if such a short time is given the men, it would seem 
to me that the active psychotherapy doesn’t cover enough time. I 
would doubt that the slap on the back and the brief reassurance that 
could be given the men in such short interviews would be very telling. 

Then, also, in regard to prevention and therapy, it occurs to me 
that there are three factors that may be of importance. One of them 
is what Dr. Strecker mentioned this morning—idealism. I am won¬ 
dering if in dealing with the men in their group talks or individually, 
the ideal could be stressed more than it is at the present time; that is, 
if it could be put across to them why they are fighting, perhaps for 
freedom, if that seems to appeal to the therapist as being the point of 
view to pursue. 

Then also I think a point that Dr. Hall brought up this morning 
could be emphasized in therapy, the idea of fatalism. We under¬ 
stand from the last war that if a man had the idea that this particular 
splinter or that particular bomb had his tag on it, well all right, he 
accepted it. Now, it seems to me that it might be stressed in therapy, 
let the man’s autonomic system jangle and jingle as it will, it will do 


130 


TRAUMATIC WAR NEUROSES 


no good, and he might as well realize that if his time has come, that 
is all there is to it. 

Also, a third point might be used in therapy. That is the idea 
of perspective. I have the impression that not only in this sort of 
problem but also in the neurotic situations which we see in every-day 
life, the individual’s ego, his self-importance, is too marked and he 
doesn’t have perspective. After all, he is just a fairly small atom in 
a huge universe. It seems to me that an attempt could be made to 
put across to the men the idea that it doesn’t make much difference 
really whether they live or die; and it doesn’t. Of course, they think 
it does, because their own egos are so important, but I think the idea 
of relative unimportance could be exemplihed in such a way that 
some of them would accept it and it might be helpful. 

Dr. William A. Bellamy: In answer to Dr. Millet’s question 
about rehabilitation we have been very interested in this problem 
and have investigated the existing facilities and made inquiry con¬ 
cerning the Barden Bill. 

The New York State Bureau of Rehabilitation and related 
agencies will care for a certain number of these cases. The Federal 
Government may loan money to the State for vocational training, job 
adjustment and rehabilitation, but no money is provided for main¬ 
tenance of these men during the period of training. 

It is considered best to decentralize the handling of these cases. 
They may be returned to the state in which they have a legal resi¬ 
dence. New York State is permitted to rehabilitate out of state resi¬ 
dents upon guarantee of reimbursement from the state in which the 
man has legal residence. 

We have received pledges of help from unexpected sources. For 
example, the National Society for Crippled Children of the United 
States of America has offered its facilities to help with this problem. 
This organization has representatives in foreign countries '^vho can be 
called upon to visit in foreign ports seamen who need rehabilitation. 
The morale is greatly improved/when an American seaman in a 
strange land in the midst of strangers can have a representative visit 
him and explain the facilities for rehabilitation which will be open 
to him as soon as he returns to this country. 

It is important that the ground work for rehabilitation be laid 
while the patient is still in the hospital. Otherwise, valuable time is 
lost. An unfortunate case recently came to my attention. A seaman, 
torpedoed off Iceland in December, 1941, v^as hospitalized for six 


PREVENTION 


131 


months in Halifax. Due to frostbite and gangrene, both feet were 
amputated just above the ankle. He was transferred from Halifax 
to the United States Marine Hospital, Boston, Massachusetts. He 
eft this hospital against medical advice and came to New York City, 
where he stayed with friends. The case came to my attention in 
October, 1942, and then only because the friends could not possibly 
care for the patient any longer. 

This patient became depressed and felt there was little use in his 
going on living. At the Health Center at the United Seamen’s Serv¬ 
ice Club House, I treated this patient for his mental condition, and 
also arranged for vocational analysis and guidance at the New York 
State Bureau of Rehabilitation. The result has been very gratifying 
and the patient is now on his way to recovery. 

We hope to prevent the occurrence of such situations by working 
out a plan of referral of cases for rehabilitation while they are still 
under treatment in the hospital. 

Domiciliary care is still a big problem in these cases. At present 
there are no Federal or State funds available for this purpose. Many 
of these men are denied rehabilitation facilities because they have 
no place to stay. If there are any of you who have any ideas on how 
we can provide domiciliary care for these men, it would be very 
helpful. 

Dr. Grace Baker: I would just like to make a point to you again \ 
of the value of individualistic nature of the seamen. Dr. Millet has 
asked about what we can do as alternative plans when we think they 
are not able to go back to sea. They themselves decide it. From the 
men with whom I have talked, I have found that any suggestion I 
had, although they responded to the interest and the feeling that we 
cared, was not followed. They usually went out then and made their 
own plans. 

One of the things I found particularly was that a man recognizing 
that he was not yet feeling well enough to go back to sea, usually 
went into shipbuilding. They made those plans themselves, and on 
two or three occasions, as I now feel, I too early suggested a plan for 
them. I mean I had definite jobs they could have done. They cer¬ 
tainly appreciated the interest but when I found that they had a 
plan of their own and certainly most times I thought it was a much 
better plan. 

I feel quite strongly the need to emphasize that the man in going 
to sea has made some attempt at solving his problem, and I would 


132 


TRAUMATIC WAR NEUROSES 


hate myself very much to feel that the sign of individualism meant 
illness. If he has had a problem at home, I think the very fact that he 
isn’t willing to take it may be a very healthy sign. We might feel 
that he should perhaps stay and fight the thing out. Well, he may 
not be that well. He may not be well enough to do that but I think 
it is healthy, if the circumstances are unfavorable, that he doesn’t 
put up with it. I think that that sign of his individualism, that evi¬ 
dence of fighting, indicates a self-reliance in him and I certainly 
thoroughly agree with Dr. Rado that, although you can see the 
great sense of security he may get from an officer on whom he relies, 
it is essential, too, that that be balanced by using all of his own 
efforts, because he may sometimes find himself alone. 

Chairman Overholser: This morning Dr. Watters was called 
on but wasn’t in the room at the moment. May we hear from you. 

Dr. Watters, all the way from New Orleans? 

0 

Dr. Theodore A. Watters: Mr. Chairman, I appreciate your 
calling upon me after so many distinguished speakers. A few notes 
made here and there as the day has gone along are to be given 
commentary. 

I have given thought for a considerable period of time to the 
need for an overall centralized form of psychological indoctrination 
on democratic principles for all of our men who go into our various 
services. There are men here who are far better students of military 
affairs than I, but I can’t help but be reminded of Dr. Mira’s state¬ 
ments, and those of medical officers who have come to me from 
adjacent camps and spoken about the confused thinking that some 
of their patients have about the reasons for fighting and what they 
want to accomplish as a result of their fighting. I merely bring this 
out in view of the fact that numerous speakers have spoken about 
the ideals of these seamen, and we certainly must serve to build up 
ideals in them as to why they are fighting and participating in this 
huge effort that is before us. Their psychological as well as their 
physiological equipment must be marshalled and well directed. 

I regret to see us undermine any of the work that we have done 
for the past twenty or so odd years in trying to modify the fixed and 
prejudicial thinking, both lay and medical, as to what nervous 
disorders actually are. They are nervous disorders, and the public 
simply has to be educated to accept them for what they are and what 
they can do. Therefore we must formulate our plans to handle them 


[. PREVENTION 133 

[ as they are, the best way that we can. We must not play ostrich. 

I Rather must we shape lay and medical thinking on different premises 

j and according to more honest and realistic attitudes. What is needed 

j still is more enlightenment by medical workers, and a more courage¬ 

ous, diplomatic, consistent and enterprising plan and policy as to 
diagnosis, disposition, and management. It is astounding how even 
today we fall for the magic of thought. Changing the name does 
? not change the thing. As a rule it is useless to put new tags on old 
; things; rather must we create new attitudes. 

We all remember at one time that we thought in terms of epi¬ 
lepsy, whereas now we think in terms of the epilepses. At a meeting 
in New York during the holidays, there was one session about fatigue, 
and, candidly, one gained a great deal from hearing the various 
workers bring out all the different kinds of fatigue states that human 
beings have and under what conditions they are acquired. So it is 
well that we avoid thinking of fatigue just as one entity, but rather 
think of it as a constellation of allied sensations and physical and 
emotional states. 

I think it might be well for some of our military minds to draw 
conclusions from comparative observations and study of our soldiers, 
who certainly aren’t fighting for mercenary gain, and those soldiers 
who are under duress and fighting as conquered people. We might 
get some leads as to the incidence of breakdown among these respec¬ 
tive groups as well as other interesting psychological data. 

I am sorry that Dr. Karl Menninger did not make remarks about 
the selection on the part of the seamen of their particular work, and 
the psychological motivation and structure behind such choice of 
service. He is competent to give us a nice discussion on this matter. 
Perhaps he will later. 

I personally would be very happy to receive the handbook which 
is to be given seamen, and about which Dr. Blain has spoken. It is 
worth while for us to read it for our own enlightenment and pos¬ 
sibly with the hope of making suggestions. 

The whole pattern of helping these seamen is what one might call 
a mellow attitude towards their nervous disorders, which as a frame 
of reference might be applied to other services. We would do well 
to watch this program because it certainly provides a more flexible 
way of dealing with these illnesses that we have had in the past. 

I can say from my personal experience derived from helping 
some men of the armed services, in the Army and Navy, while they 
were on furlough, that they aren’t so willing to completely expose 


0 


134 


TRAUMATIC WAR NEUROSES 


themselves and their problems within the setting of discipline; where¬ 
as, when they have access to a civilian doctor, they often tell about 
problems that were not detected in the services. 

Again, Mr. Chairman, I thank you very much for the opportunity 
of making these remarks. 

Chairman Overholser: Dr. Musser, it would be a joy to us if 
we might hear a word from you, sir, in closing the discussion. 

Dr. John H. Musser: I feel very much as if I were a mouse in 
the lion’s den, not being a psychiatrist and not being in the uni¬ 
formed services. 

I do have one or two impressions from a somatic point of view 
that I might bring out. I must say I do not like the term “war 
nerves.’’ I think that that has certain implications which are not of 
the best. Some of you may remember that some eighty years ago Dr. 
DaCosta coined the term “soldier’s heart,” and that term lasted up 
to World War I, when the condition was called neurocirculatory 
asthenia. I think it was an excellent term. It certainly did not imply 
at all that the soldier was, as the term “nervous” does, somebody who 
was unstable and who might be a neurotic or whatnot. ^ 

One other thought I had about all you psychiatrists in general was 
that you talk only about the psychiatric treatment of these people. 
Well, a lot of you know that they often do not have fears expressed 
as such and do not have headaches and do not have bursting noises 
in their ears and all that kind of thing, but they do have somati<^ 
expressions which are very definite. 

As to the heart, which I mentioned a second ago. Dr. DaCosta 
expressed himself very well indeed with reference to soldiers, as well, 
I imagine, as to seamen. The term neuro-circulatory asthenia implies 
that they have marked asthenia, that they have tachycardia, that they 
have a very unstable blood pressure, that they complain of marked 
shortness of breath, and that their dyspnea is so great they can not 
do anything physical. I think that consideration of the somatic 
expressions really should have some thought in your mind. 

Incidently, in the plan that Dr. Blain has promulgated for the 
treatment of these men, I do not see any very great accentuation 
being made on physical exercise, which I think for this type of neuro¬ 
sis, a particular type of neurosis if you wish to call it that, is proba¬ 
bly as satisfactory a form of treatment as any. I remember in our 
hospital in the last war we had some forty of these young soldiers and 


PREVENTION 


135 


our psychiatrist worked with them. I must confess I think that the 
best results were attained by the man who had charge of physical edu¬ 
cation at the University of Pennsylvania. He had setting up exercises 
for these men and graded their exercise. Then he took them out 
for a hike in the afternoon, some of them for only half a mile and 
some for a mile and some for three miles. But, of course, he took 
the elementary cases and the psychiatrist had the difficult problems. 

I think the whole discussion today really has been extremely in¬ 
teresting and I am very glad indeed to have had the opportunity of 
hearing so many distinguished psychiatrists. 

Chairman Overholser: Thank you. Dr. Musser! 

Dr. Hugo Mella: Our organization, the United States Veteran’s 
Administration, determined some years ago that the care of func¬ 
tional nervous disorders is an out-patient problem and that as a rule 
hospitalization, except for diagnosis or treatment of complicating 
disorders, is not wise. The re-socialization centers established for 
seamen suflEering from neurosis appear to be the ideal. 

There are still approximately 36,000 veterans of World War I 
drawing monetary benefits for disabilities due to functional nervous 
disorders—this is, twenty-four years after the war. Therefore, no 
efforts to alleviate the acute neurosis occuring at this time should be 
neglected. 

Chairman Overholser: Thank you! Dr. Mella. 

Dr. Viola W. Bernard: It would be merely repetitious to fur¬ 
ther discuss the principles of prevention and treatment so fully 
covered by other speakers. I will confine comment therefore to 
emphasizing the extraordinary opportunities for clinical research 
and mental hygiene education this program offers, in addition to its 
immediate function of providing essential services to seamen. 

Particularly favorable experimental conditions prevail for the 
much-needed investigations of the whole group of psycho-physio¬ 
logical reactions to traumatic experiences, which include the trau¬ 
matic neuroses, states of “combat fatigue”, and other psychosomatic 
disorders. Thus, the number of variables and unknowns is reduced 
because the merchant seamen present a relatively homogeneous group 
in terms of certain basic personality and socio-economic factors. 
(This will not apply in the same way to the newly recruited trainees. 


136 


mAUMATIC WAR NEUROSES 


of course.) There is a degree of uniformity in the stresses to which 
the men are exposed; the nature of the traumatic event, as well as 
conditions immediately preceding and following it, can generally 
be known; subsequent reactions in a controlled environment can be 
observed. 

The program also provides a valuable laboratory for testing and 
perfecting methods of combined treatment through the coordination 
of several different professional groups. The clinical team-approach, 
as known for instance in the child guidance field, and proving so 
successful in some Army mental hygiene units, is being worked out 
in its own form for the seamen. Here we find that the psychiatric 
objective of promoting, maintaining and restoring a sense'of security 
is furthered by the integrated use of other contributing clinical and 
non-clinical resources. There is much to be learned and developed 
along these lines. 

As regards the problem of psychiatric stigma, I believe we 
should pursue a two-fold course: in dealing with very large numbers 
of patients who need rapid first-aid methods, the emergency doubt¬ 
less warrants concessions to their dread of the “nut doctor” by some 
camouflaging of psychiatry. Men who would otherwise refuse treat¬ 
ment may thereby obtain the help they need. But by the same 
token, namely, a widespread emergency, we have a propitious oppor¬ 
tunity to make great gains in our long-term mental hygiene task of 
educating the stigma out of the popular attitude. It would seem 
tragic to forego this chance towards legitimizing emotional disorders 
by virtue of their universality and publicly acknowledged presence 
in time of war. 

Chairman Overholser: Well, if time permitted, we should 
have hoped to hear from a number of others. Dr. Glueck and Dr. 
Sullivan and Dr. Kimberly and Dr. Malamud. We are a little over 
our time already. 

Dr. Howard W. Potter (Read by Dr. Blain in Dr. Potter’s 
absence): Modern warfare imposes extraordinary stresses and 

strains on the human organism which sometimes overtax the adap¬ 
tive capacity of the total personality. The psychological and phy¬ 
siological factors responsible for the breakdown of the total psycho- 
biological economy resulting in a widespread psychosomatic dis¬ 
organization still require considerable definition. The better we 
understand the basic pathological disturbances of the body meta¬ 
bolism, the breakdown of hormonal inter-relationships and the 


PREVENTION 


137 


disorganization of the psychological structure, the better the position 
in which we shall be to establish effective preventive measures and 
a rational system of therapy. 

The medical department of the War Shipping Administration 
(R.M.O.) has gotten off to an excellent start, but it must go further 
in order to meet its fullest responsibilities and obligations to the 
thousands of those men who will develop traumatic neuroses of war 
in this world wide conflict. Neither the Medical Department nor 
its sponsoring agencies can afford to neglect the unusually favorable 
opportunities for medical research in this special field of military 
medicine. 


Chairman Overholser: We will reconvene at six. 

The conference adjourned at 5:40 p.m., Eastern War Time. 


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BANQUET SESSION 


of the 


Conference on Traumatic War Neuroses 

in Merchant Seamen 


CONCLUSION 

The banquet session of the Conference on Traumatic War Neu¬ 
roses in Merchant Seamen was held in the New York Academy of 
Medicine, New York, N. Y., at 8:15 p.m.. Eastern War Time, Sur¬ 
geon General Thomas Parran, United States Public Health Service, 
acting as toastmaster. 

Toastmaster Parran: Ladies and Gentlemen: 

It was two years ago that I landed in Great Britain. One of my 
first experiences after I landed there was to have a modest meal in 
the family of a working man, a laborer in Bristol. Before we sat 
down to eat, a blessing was asked and the blessing was this: “For this 
food that we are about to eat, we thank Thee, dear Lord, and the 
British fleet.” 

And the food they were eating, even then, was no more than we 
have discarded from this bounteous table this evening. I recall that 
because of the subject of our discussions today. Perhaps there are 
American airmen and soldiers in far parts of the world who are much 
more concerned about the problem that we are discussing today 
that we are here in the United States. I can visualize some of our 
boys in far parts, in North Africa or the Southwest Pacific, who may 
be saying, “For this crate, that we hope to fly, we thank Thee, dear 
Lord, and that sailor guy.” (Applause) 

141 


142 


TRAUMATIC WAR NEUROSES 


We have been talking today, and shall continue our discussions 
this evening, about that sailor guy,—the unsung heroes in the battle 
of the supply lines. The speakers this evening will continue and 
summarize the rather technical discussions which we have had today. 

Before introducing them, however, I can’t refrain from trespass¬ 
ing for a few minutes upon their time to think out loud with you my 
own reactions as I sat here today and this evening and add to that a 
comment which one of our guests made to me. All of our strategy 
today, all of our tactics, have been of a defensive character. How 
can we prevent a loss from combat fatigue? How can we add to the 
total efficiency of that-sailor guy? 

And then all of a sudden, one of our guests here today—I shan’t 
embarrass him by mentioning his name—said to me. Dr. Parran, I 
think psychiatry is coming into its own. This meeting is a first ex¬ 
ample, but, said he, don’t you think that when this war is over, it 
will be the psychiatrist who will have the great job to do? Don’t 
you think that our task, the task of psychiatry in America, is the 
mental regeneration of Europe? 

Think with me, if you will, what a great projection it is from our 
discussions of defensive tactics and strategy today to the concept 
which this eminent man holds—the psychological regeneration of 
the enemy countries. I had not thought in those terms. I have been 
concerned with the control of epidemics, the prevention of starva¬ 
tion, the alleviation of the worst of the famines with which we shall 
be confronted. I am sure that all of us have realized that as we 
reoccupy one area after another, we are likely to find a scorched earth. 
Hunger and hatreds will be .the major problems. In very truth, 
a new civilization will need to be built upon this scorched earth. 
Then we shall need another type of expeditionary force, a force in 
which American medicine necessarily will play the most important 
part. 

Today the remark of our colleague lifted my sights far beyond 
the terms in which I had been thinking. I had been thinking in 
terms of typhus epidemics and the lack of medicines and hospital 
beds and nurses and doctors and community organization and water 
supplies and all of the other physical things. But you, this group 
of eminent psychiatrists, should you ponder the statement of one 

of your colleagues as to the future mission of psychiatry in rebuild¬ 
ing the world. 


CONCLUSION 


145 


Before introducing the speakers of the evening, I should like 
to welcome here a number of workers on the staff of Dr. Blain 
and his colleagues. I was inquiring as to who were these attrac¬ 
tive ladies who had joined us for dinner. Without introducing 
them individually, I can only say that we welcome their presence 
here this evening, because we have been hearing today about the 
fine work which they are doing. 

Moreover, I should like to present to you another one of our 
guests. We had hoped to have two. We had hoped to have the lady 
who had donated the beautiful home at Oyster Bay—Mrs. Kermit 
Roosevelt. Unfortunately, she has not been able to get here on 
account of the weather. But I should like to present to you Mrs. 
C. S. Cutting, of Gladstone, New Jersey, who has contributed a 
very splendid home, one of those that we have been talking about 
today. Mrs. Cutting, won’t you stand? 

When it comes to raising money, one not only needs a benefact¬ 
ress like Mrs. Cutting but also someone who is able to go out and 
raise some cash. The United Seamen’s Service, Inc., has been very 
fortunate in the person whom it has selected to raise money with 
which to enter many sectors of this job which the government has 
not been prepared to do. I should like to introduce this gentleman 
who has had a large experience here in The Greater New York Fund 
and who is now the National Executive Director of the United 

Seamen’s Service—Mr. Douglas Falconer! 

/ 

Mr. Douglas Falconer: Mr. Chairman, Ladies and Gentlemen: 
There are, I am sure you will all agree, two broad approaches to 
nervous disorders. There is the approach to the fully developed 
disorder, which falls squarely within the domain of modern psychia¬ 
try. And then there is what we might call the preventive approach— 
the attempt to keep disorders from developing. Some day, let us 
hope, all medicine, psychic and somatic, will be preventive. But 
that day is not yet here, unfortunately. 

The United Seamen’s Service is organized so as to take into its 
purview these two approaches. Our Medical Division, operated in 
collaboration with the War Shipping Administration, addresses itself 
to the task of dealing with developed nervous disorders, most of which 
are transitory in character. More severe cases are referred to appro¬ 
priate institutions. We do not attempt to cope with them. 


144 


TRAUMATIC WAR NEUROSES 


I leave it to Dr. Blain and his associates to tell you about their 
work, which is being observed with so much interest by medical 
specialists of the various armed services. I think it is very gratifying 
to learn that no other war-related agency has preceded us in 
adapting this same technique of dealing in small numbers with 
sufferers from traumatic war neuroses. 

But, the Medical Division apart, all our work in other directions 
might correctly be regarded as prevention of psychic and moral dis¬ 
organization among seamen. This, indeed, is what all morale-build¬ 
ing work really boils down to: the prevention of psychic breakdown. 

I have met many of our seamen. They live, these days, under 
terrific tension. Life on the sea even in normal times is onerous 
enough. But under the circumstances in which these men now 
function it is sometimes incredible that any of them should keep 
their mental stability as they do and ship out again and again as 
they do. 

I have talked with a good many of these men who have been on 
the Murmansk run, men who have been torpedoed repeatedly. They 
come back to shore shaken. What we and others are able to do for 
them is welcome. But they want, nevertheless, to ship out again 
right away. Their fortitude and vitality are amazing. 

In order to meet their wartim,e needs, we have elected to do vari¬ 
ous things: First, to establish for those who have been torpedoed 
or who have otherwise suffered shock, convalescent centers where 
they can be given care and rest and treatment. We already have five 
of these established. 

The second thing we try to provide is overnight accommodations 
in domestic and foreign ports where there is no other place for sea¬ 
men to go. We have opened the Imperial Hotel in Glasgow and the 
Royal Yacht Club in Gourock, Scotland. A hotel in Cardiff is to be 
opened soon, to be followed by one in Liverpool, and others in Cape¬ 
town, Honolulu, Trinidad, Durban and various other distant ports. 
In all these places, as well as in many here at home, we provide over¬ 
night accommodations, food, and medical and social service. 

Now, these programs, as I say, are unfolding. Attached to each 
one of them, however, is one part of the service that I want to dwell 
upon at considerable length. We call it Personal Service, but it is 
better known as social service. The terms social service and social 
work are not acceptable to seamen and the term personal service is. 
We have assembled, therefore, a group of highly skilled social work¬ 
ers who are rendering this “personal service” which is not unrelated 


CONCLUSION 


145 


to the work you are particularly interested in. 

Working along the avenue of “personal service” we find many 
opportunities to release tensions and to relieve anxieties, some of 
them in very simple but helpful ways. 

For instance, a licensed seaman who had followed the sea some 
twelve years came to us recently very deeply worried. He had suffered 
chronically from a sore throat, had difficulty with his speech and 
pressure on the larynx, and was afraid to go to a doctor. He feared 
he had cancer. The problem there, of course, was to persuade him 
to consult-a doctor. It was, manifestly, a job that called for certain 
skills in reassuring and persuading him. When he was examined a 
non-malignant growth was found. It was treated successfully. He 
is now back at sea, and just before he went he said he would enjoy 
the best Christmas at sea he had had in many a year. 

There was another seaman who feared he was going deaf. We 
helped him purchase an acousticon which he paid for in installments^. 
He is now at sea, relaxed, relieved, his worry gone. 

There was yet another seaman, who had been torpedoed twice, 
bombed and machine-gunned. He also swam through the shark in¬ 
fested waters. Upon his return to the United States he be':*ame 
attached to a girl in San Francisco and gave her a good deal of his 
money. Before leaving for New York to ship out again, he found 
she was venereally infected. As he arrived in New York he felt con¬ 
fused, upset, alone, worried. He came to us and offered us $10 just 
to listen to him. He wanted to talk to somebody. Well, we listened 
to him—without charge of course—and got the girl under treatment 
in San Francisco. He shipped out to sea again, relieved and n 
assured, able to discharge his duties. 

There was also a seaman who had himself become infected abroad 
and had been cured. Upon return home, his wife said she didn’t be¬ 
lieve the cure part. Here was a family conflict in the making. But we 
were able to get both of these people examined and relieved of their 
anxiety. 

Still another seaman came to us not long ago, very much worried 
because he said the police were after him. With his permission we 
consulted both the local police and the FBI. There were no charges 
against him, nobody was looking for him, and the man at once 
relaxed. 

One seaman arrived home following torpedoing, knowing that his 
wife in Queens had given birth to their first child. This poor fellow 
was just off the dock and he sat there weeping, worried, afraid to go 


146 


TRAUMATIC WAR NEUROSES 


home. He feared something terrible had happened to his wife. We 
located and brought her down to meet him. They embraced and he 
felt better. 

Just one more incident that happened recently, concerning a man 
who had landed here in this rather hysterical condition that many of 
these men fall victim to. This man had immediately gone on a spree, 
gotten himself pretty drunk, and wound up in bed babbling that he 
wanted to talk to Mommy. Mommy lived in Virginia and she had 
moved. He couldn’t remember the name of the town she lived in. 
And here he was in this terrible state of nervousness, couldn’t relax 
until he talked over the phone to Mommy. Well, one of our social 
workers went to the Public Library and got a guide that gave the 
names of all the towns in Virgina. We proceeded to read these names 
to him. Fiinally, we got to the name that registered in his mind. So 
we located Mommy and he talked to her over the phone. He 
relaxed at once. 

These are perhaps simple little illustrations of the sorts of worries 
that these men have. We, for our part, are trying to provide tliem 
with somebody who will be sympathetic and friendly and will let 
them tell about these things before they enlarge in brooding to the 
point where we would have to give the men more intensive and long- 
continued treatment. Our efforts may, we hope, obviate some repair 
work of the psychiatrists. 

These seamen, I think we have learned today, are people. Un¬ 
fortunately, a great many persons have not thought that seamen were 
people, but that they were something different, a group set aside, not 
first-class citizens. Unfortunately, too, many of the seamen have had 
that same attitude towards themselves and have felt that they should 
stay down on the waterfront when they landed, that they shouldn’t 
mix with other people in the community. 

We are trying to change that. We are trying to bring the men 
back into the community and to give them that sense of belonging 
which should be part of the feeling of all citizens. 

This is the general background of the work of the United Sea¬ 
men’s Service into which your work fits. We started out four months 
ago. There were no answers in the back of the book. We are 
experimenting. We are learning. We hope very much that you 
psychiatrists will teach us some of the answers. We are very grate¬ 
ful to you for having given this time, and we are looking forward to 
studying in print your discussion. 


CONCLUSION 


147 


I should now like to tell you in somewhat great, but brief, detail 
about United Seamen’s Service. 

United Seamen’s Service was formed in September, 1942, as a 
private non-profit organization at the instance of the War Shipping 
Administration, with Admiral Emory S. Land, War Shipping Admin¬ 
istrator, as chairman of its board, Henry J. Kaiser as president, and 
myself as national executive director. Funds for its operation have 
been forthcoming in the form of donations by the shipping and 
shipbuilding industry, the maritime labor unions, and the general 
public. Now, however. United Seamen’s Service is a participant in 
the National War Fund. 

The purpose of United Seamen’s Service is to sustain the health 
and morale of officers and men of the American Merchant Marine. 
This objective is sought (1) by operating port medical offices 
and convalescent centers in close cooperation with the War Shipping 
Administration; (2) operating abroad residential clubs and health 
and repatriation facilities for merchant seamen; (3) providing resi¬ 
dential and recreational clubs in the leading port areas of the United 
States; (4) making available to merchant seamen entertainment as 
well as recreation, skilled help with personal problems, recreation 
kits, health literature, survivors’ kits, emergency clothing, emergency 
assistance of all kinds, etc. Within the framework of its extensive 
and growing facilities. United Seamen‘s Service offers merchant sea¬ 
men a wide variety of special services designed to ease their minds 
of many burdens. 

In conjunction with the War Shipping Administration, the 
United Seamen’s Service maintains seven port medical offices 
in the United States; the number is to be increased. With the War 
Shipping Administration, it also maintains five convalescent centers 
for men just discharged from hospitals, men suffering from “war 
nerves,” and men gripped by various types of exhaustion and fatigue. 
In the United Kingdom, USS-WSA maintain medical facilities for 
merchant seamen in Scotland and Devonshire. USS-WSA is soon to 
open a vocational re-training project for seamen injured by enemy 
action and unable to return to sea. The project will be housed in 
the headquarters of the Medical Division at 107 Washington Street, 
New York City. 

Residential clubs abroad will soon be located in the following 
places: Glasgow, Gourock (Scotland), Cardiff, Liverpool, Durban 
(Union of South Africa) and Oran, Casablanca and Algiers (North 


148 


TRAUMATIC WAR NEUROSES 


Africa). Services are also being established in Honolulu, Hawaiian 
Islands; Noumea, New Caledonia; Port of Spain, Trinidad; Para¬ 
maribo, Dutch Guiana; San Juan, Puerto Rico; Capetown, Union of 
South Africa; Tunis and Bizerte, North Africa and Basra, Iraq. Plans 
are in progress for establishing services in Cairo, Bandar Abu Shehr, 
(Iran), Bombay, and in all areas into which our armed forces pene¬ 
trate in Europe and Asia. 

Residential clubs in the United States are in operation or will 
soon be, in New York City, Baltimore, Norfolk, Wilmington, (N.C.), 
Charleston (S. C.), Mobile, New Orleans, Galveston, Port Arthur 
(Tex.), Houston, San Pedro, Wilmington (Cal.), San Francisco, 
Seattle and Portland (Ore.). Recreation clubs are operated as sepa¬ 
rate entities in New York City; Stapleton, Staten Island; Philadelphia 
and Seattle. 

Recreation and entertainment are offered at all the United Sea¬ 
men’s Service centers. War Shipping Administration workers and 
United Seamen’s Service personal service staff members regularly 
meet all repatriated survivors of enemy action. Daily they investigate 
problems brought to them by individual seamen and work out 
solutions. 

“War nerves’’ is the special province of the Medical Division 
jointly operated by the United Seamen’s Service and the War Ship¬ 
ping Administration, financed in major part since July I, 1943, by the 
United Seamen’s Service. 

The United Seamen’s Service aims to help in dealing with all 
disabilities of seamen. But the major part of its program is preven¬ 
tive. By providing clean, healthful lodgings at prices seamen can 
afford and by trying to do away with annoyances that might hinder 
the merchant seaman in the performance of his essential war-time 
task, the United Seamen’s Service makes a significant contribution 
to the war effort. 

Toastmaster Parran: Thank you, Mr. Falconer! 

It would be presumptuous for me to introduce our next speaker 
to ah audience such as this. All I can say is that I am very happy to 
present to this audience our next speaker. Professor of Psychiatry at 
the University of Pennsylvania, among many other titles I might 
ascribe to him, a man whom all of you know very well—Dr. Edward 
A. Strecker! 

Dr. Edward A. Strecker: Ladies and General Parran and 


CONCLUSION 


149 


guests: I know you wish, as I wish, that I had both the words and 
the wit to express our very sincere admiration and appreciation of 
this very splendid thing that Surgeon General Parran has done today. 
Perhaps it will not be too much to say that it will prove to be some¬ 
what epoch-making in both the history of psychiatry and in the his¬ 
tory of the Merchant Marine. I should like, too, to express our 
appreciation to the Macy Foundation and to Dr. Fremont-Smith for 
having made this meeting possible. 

Then, too, I wish I had the words to express the warmth of feel¬ 
ing that I think we all felt at this opportunity to meet with repre¬ 
sentatives of our Allies, the psychiatric representatives of Great 
Britain and Norway and Canada. Happily, the subject of the meet¬ 
ing expressed one of our closest bonds with our Allies, a bond which 
has been signed and sealed and is being made good to the best of 
our ability, the bond providing for the delivery of men and the 
machines and munitions of war and of food, so that they, our Allies, 
can fight for us and with us, and so that we can fight with them and 
for them. 

I am to give a summary of this conference. It is a rather large 
order. I take it that one of my functions would be to re-live with 
you, as it were, the emotional experience of this meeting so that you 
do not depart from here with too many repressions and with too 
much unexpended aggressiveness. 

One thing seems to be clear to me after participating in this 
meeting all day and that is that, contrary to general opinion, psychi¬ 
atrists are very practical fellows, not at all visionary. Perhaps they 
are as practical as was the psychiatrist in this story which is supposed 
to have happened in Macy’s store. 

A little boy was taken by his mother to select a Christmas present 
for himself. His attention and heart’s desire fixed on just one thing, 
a rocking horse which happened to be the display sample that was 
not for sale. He mounted the horse and in spite of entreaty and 
threat and everything else, he refused to be satisfied with anything 
but that particular sample horse that was not for sale, even though 
he was told he could have one just like it. 

Well, it produced a kind of crisis in the affairs of the store. The 
saleslady failed to resolve the crisis. The floor walker and the mana¬ 
ger both failed. The kid still clung to the sample horse, vowing that 
he woud have that horse and no other, no matter what might happen. 
Finally, the manager of the store said, "We have a store psychiatrist. 


150 


TRAUMATIC WAR NEUROSES 


Send for him. He will settle this very easily.” 

Thereupon they sent for the psychiatrist and stated the problem 
and he said, “Oh, very simple indeed.” 

He whispered a few words into the youngster’s ear. At once the 
boy stopped his crying and threatening and sulking and climbed 
down from the horse and said, “I’ll be perfectly satisfied with one 
of the other horses like this one,” and that was the end of it. But it 
made his mother curious, indeed, so on the way home she said, 
“Johnny, what did the nice doctor say to you that made you behave 
like such a nice boy all of a sudden.” 

“Oh, I don’t want to tell you. Mom.” 

She kept at him and finally got the answer. “Well,” he said, 
“Mom, he said to me, ‘You damned brat, if you don’t get off that 
horse. I’ll cut off your ears.’ ” 

So you see psychiatrists may be very practical indeed. 

Well, now, more seriously as you recall the happenings of this 
very fine day, it seems to me that the keynote of the meeting was set 
by Surgeon Blain who showed us some of the men, some of the pa¬ 
tients, who still had some of the wounds produced by our enemy and 
by the sea. And more than that, we were able to see how rapidly 
and effectively those wounds were being repaired by the psychiatric 
service of the Merchant Marine. 

, Then following that, as you know, the discussion rather naturally 
subidivided itself into three phases, the etiology and pathology of 
these difficulties, the treatment, and the prevention. You know how 
very ably and indeed in what masterly fashion those discussions were 
conducted by Drs. Bond, Ruggles, and Bowman. I can’t, of course, 
give you a verbatim account of the day’s proceedings. I will try to 
draw, in very crude outline, the pictures that were outlined as each 
participant in the discussion wielded the mental brush of his knowl¬ 
edge and experience so that finally a rather complete picture 
emerged. 

In the discussion of the etiology and pathology, it appears to 
be a fact that the merchant mariner is a seaman because he likes the 
sea. He feels more secure, if you will forgive a pun, when he is at 
sea. He feels less secure on terra firma. Furthermore, in a way, not 
without many exceptions, I am sure, he has less close marital and 
social bonds than those who prefer the habitat of the land. There¬ 
fore, since this is true, he is much more apt to establish a closer and 
more intimate relationship with his shipmates and with his officers. 
They are his family and the ship is his house. He prefers to have 


CONCLUSION 


151 


it on the sea rather than on the land. 

Another factor that seemed to be important in etiology was that 
the merchant seaman has no weapons with which to fight back and 
that, furthermore, attack comes as a surprise. So picture yourself 
suddenly confronted with a death-dealing surprise attack upon 
yourself and your house and without the wherewithal to retaliate. 
That perhaps describes an important element of etiology. 

We are told, too, that as far as selection goes, as to men who were 
the better equipped to go down to the sea as merchant mariners, 
those who had any tendency to any epileptoid attacks, those who were 
stammerers, those who had shown repeated maladaptations and those 
who succumbed easily to the rebuffs of life, physical and psychic, 
made poor material. 


Then, in various ways, all of them effective, the underlying mech¬ 
anism and pathology was outlined. Perhaps I could present briefly 
what might be considered a basic formula which got to be known, 
under the able leadership of Thomas Salmon, as “the AEF idea” of 
these war situations. It pictured on the one hand the operation of 
that strongest and most dominant instinct, the instinct of self-preser¬ 
vation, which leads a man, unless he is very grossly feebleminded, to 
preserve and guard his life and as the other limb of the conflict, a 
group of things, thoughts and motivations which might be summed 
up as “soldierly ideals,” ideas of discipline and training and honor 
and courage and purpose, desires to acquit one’s self favorably and 
certainly not to disgrace one’s self. So that we have here the two 
limbs of an apparently irreconcilable conflict because a man cannot 
be a good soldier or a good sailor or a good merchant seaman without 
exposing his life to danger. 

Then when a third element was added, probably the least impor¬ 
tant in many ways, the precipitating circumstance—which in the 
soldier might be being bowled over by the concussion of a shell and 
in a merchant seaman it is usually much more serious,—being tor¬ 
pedoed, exposed in the cold and rough sea, deprived of food and 
water, etc. Here, often, is the extra straw which breaks the emo¬ 
tional back, and then, there is the pathological solution of “combat 
fatigue.” 

Now, you can go much deeper and, of course, very rightly, but 
from the standpoint of what is the important thing for getting your 
patient well, perhaps I have stated a good working and workable 
basis. 

We discussed also the very hypothetical question of the threshold 


\ 


152 


TRAUMATIC WAR NEUROSES 


at which men break. It has to be very hypothetical. Every individual 
has a breaking point in his psychic mechanism, as every individual 
has a breaking point in his cardiovascular system or any other part 
of his body or organism. In the Merchant Marine, it seems to take 
a very heavy load indeed to reach that breaking point. So I think, 
as Dr. Blain very rightly said, we are dealing here in many instances 
with men having perfectly normal resistance in whom the breaking 
or saturation point had been reached because of undue hardship and 
terror and danger to which they had been exposed. 

We heard, too, of something we knew before: that fear is a saving 
and protective thing; that men need to be taught not to be afraid of 
being afraid, but rather need to be taught methods of controlling 
the perfectly natural reactions to fear. And we discussed treatment 
in its various phases, the immediate treatment and the subsequent 
treatment. 

Perhaps here I should like to spend a minute and say that the 
Merchant Marine is very gravely handicapped because certainly the 
time for golden therapy is immediately after the occurrence of the 
“combat fatigue.” Then, as we used to say in the A.E.F., the symp¬ 
toms are still warm and in the making. Of course, the Merchant 
Marine can’t have a psychiatrist on every freighter, but I suggest that 
this is one of the problems to which increasingly better answers must 
be found. Perhaps, training some men, not psychiatrists, who can 
render that important first aid at that golden time for therapy, might 
be feasible. Even a chance unwise remark at the time the sailor is 
emerging from his befogging of consciousness may do a great deal 
of damage: “If it had been a little closer, you would have been dead.” 

I remember very well years ago at the outpatient department of 
a hospital seeing an enormously powerful and beautiful muscular 
specimen of manhood, a Negro, brought in. He had been in a little 
exchange of pleasantries with razors, and he had a small laceration 
of his back which wasn’t very deep. He was taking it all in his stride, 
until an intern said, “If that had been a half inch nearer the midline, 
you would be paralyzed.” 

Well, I followed the case, through curiosity. Ten days later the 
big negro came back crawling in on all fours; he was “paralyzed.” 
So that the unwise suggestion made at a very critical time may do 
a very great amount of harm. 

Among other treatment considerations, the importance of giving 
the seaman an opportunity to unload his accumulated pathological 
material so that his psyche may be desensitized, so that he can “work 


CONCLUSION 


153 


out with appropriate emotional reaction the thing he has been 
through, was emphasized. The necessity of providing him with a 
kind of insight was stressed. It was said, too, very rightly, that one 
must not forget that there is a real kind of shell shock, a structural 
one with brain damage, and that the importance of determining and 
discriminating between this and functional conditions is of the great¬ 
est therapeutic significance. 

There is a concussion syndrome which involves destruction of 
central nervous substance. I remember reading a very interesting 
account by a French neurologist in the first World War. He de¬ 
scribed three French soldiers leaning against a fence, apparently all 
within the same range of concussion from an exploding shell. The 
first soldier dropped dead instantly and, undoubtedly, if he had been 
autopsied, he would have shown many punctate hemorrhages in his 
brain and other parts of his central nervous system. The second 
soldier eventually had a so-called war neurosis, and the third took 
to his heels and ran like the dickens. 

We spoke of sleep and the possibility of controlling sleep and 
lengthening sleep as a therapeutic agent. 

Then Dr. Blain described and we discussed what seems to me 
to be a most important contribution to the psychiatry of the war, 
the establishment of rest houses in an informal setting without 
nurses, with a house mother, without the atmosphere of a hospital, 
but at the same time .without the danger of psychological isolation¬ 
ism from the dangers to which the seamen had been exposed and with¬ 
out the likelihood of producing undue repression of their war 
experience. 

Psychotherapy is a matter which stops at the level at which you 
think it wise to stop. That is all I can say in the discussion of it. 
There are many men whose needs will be well met by something 
that might smack of shallow and casual psychotherapy. It removes 
the symptoms and gives a little insight to go on. That is enough for 
that particular patient and the group that he represents. In other 
cases there well might be required the most profound searching of 

the deeper layers of the human psyche. 

Of course, we stressed such things as occupational therapy and re- 
educational methods, all, I think, having in mind that the goal that 
is the ultimate salvation of a temporarily crippled man is that he get 
back to the sea with his defenses strengthened, perhaps even stronger 

than they were before he had his difficulty. 

In prevention, we spoke of the importance of strengthening one 


154 


TRAUMATIC WAR NEUROSES 


limb of the conflict, self-preservation, so that it became strong 
enough to dominate, for the time. These men need not feel inferior, 
as I fear many of them do. There are things we can do which will 
remove that feeling of inferiority. There are things being done. 
There can be a pride of service which will be equivalent to the pride 
of service in the Army or the Navy. There might be such things as 
distinctive decorations, because certainly there is no greater bravery 
in the Army or in the Navy or in the Air Forces than has been wit¬ 
nessed on the gray and lonely vastness of the sea. 

One might even think in terms of the Women’s Auxiliary Corps. 
I don’t know whether you would call them the “minnows” or some¬ 
thing else, (Laughter) but they might be indeed very helpful, help¬ 
ful in boosting their morale so that the man has an honest pride in 
the very fine and noble thing he is doing. And then I think even 
the relatively small frequency of these reactions will be even less. 

There are extra burdens which the man carries which are impor¬ 
tant in prevention. These men, like many men in the Army and 
Navy, are carrying just as much as they can carry and a little extra 
burden may break them. By extra burdens, I think of things that 
we saw so many times in the Army, a boy getting by and doing a 
pretty good job under difficult circumstances until he gets a “pleas¬ 
ant” chatty letter from a friend of his in his home town who says, “I 
saw your girl at the park last Sunday night with two very nice fel¬ 
lows.” Or else he gets a letter from his wife, in which she says, “We 
are having a pretty tough time. We can’t get by on the allotment. 
Most of the children are sick. I am pretty sick myself. I hope you 
are well and happy.” 

That kind of a letter is just enough to turn the scales so that one 
of these reactions is precipitated. 

Another thing to strengthen the morale of these men who so 
bravely do their duty is to have them identified more closely with 
other branches of the service. /After all, it is a very closely knit 
proposition. I don’t mean it is possible for the seaman to get to 
know personally the man who is going to shoot the gun he delivers, 
but there can be an interchange. I would suggest that men from 
the Army and Navy be entertained at some of the headquarters and 
clubs and unions of the Merchant Marine, and vice versa; so that 
there is not only the theoretical but the actual understanding that 
we are all doing this thing together. 

I want to conclude by saying anything is only as important and 
as sound and as intact as are its connections—the receiving station 


CONCLUSION 


155 


may be perfect and splendid and the sending station likewise, but 
unless the connection between the two is intact and functioning 
smoothly, it is just as though they did not exist. So this meeting, in 
a sense, was devoted to making sounder, to making more intact, and 
to making more efficiently functioning the connection between send¬ 
ing and receiving in this war. And the connection between “here” 
and “over there” is the Merchant Marine. 

Merchant seamen have been treated as step-children. If they are 
not too distrustful of psychiatrists I think I might offer this resolu¬ 
tion: We hereby adopt them as the children of psychiatry. 

Thank you! 

Toastmaster Parran: The last speaker on our program is a 
man whom I have known for a number of years, ever since I have 
been in Washington. I think of him as representing the finest type 
of governmental service. Trained in sociology and an assistant pro¬ 
fessor, he rose to be an Assistant Secretary of Labor, among other 
positions, and now is the director of a very important division of the 
War Shipping Administration. 

It gives me great pleasure to present to you Mr. Marshall E. 
Dimock. 

Mr. Marshall E. Dimock: Dr. Parran, Fellow Guests, Ladies 
and Gentlemen: Dr. Stevenson said this afternoon that the big prob¬ 
lem of prevention is to harden seamen to a particular situation. 
When I heard him say that, I caught on to why it was that Dr. Blain 
told me I should attend as many of these sessions as possible before 
speaking this evening; because, of course, he had it in mind that I 
would have to be hardened to this particular situation. 

One of the most interesting things that I have observed in Wash¬ 
ington, and I dare say that Dr. Parran has, too, is the exclusiveness 
of various professional groups, which is one of the difficulties that 
we have in getting on in the prosecution of the war. Just before 
going to the War Shipping Administration, for example, I was in a 
lawyers’ department, the Department of Justice. I am not a lawyer. 
I am a Ph.D. and a professor of political philosophy and public law, 
but not admitted to the Bar, and hence not a lawyer, and the lawyers, 
of course, have their own professional conceit. And so it is with 
every group. 

As I was thinking about the problem of hardening, although that 
word hadn’t occurred to me when I was considering this talk, I 


156 


TRAUMATIC WAR NEUROSES 


naturally tried to determine what there is in my background and 
in your background which affords a common foundation for interest¬ 
ing you, because it was a matter of adjustment—and adjustment, I 
take it, is a synonym for hardening. 

Incidentally, Dr. Meyer talked about the tyranny of words, and 
I was very much interested in that. This is the way the rationali¬ 
zation ran, and I must give you the rationalization because that is 
the way I am going to establish my rapport with you. 

My first thought was that there are the pure sciences, such as 
chemistry and physics, and then there are the social sciences such as 
economics and government, which is my field, and then in between 
there are certain applied sciences of which medicine is one, or at 
least that is the layman’s idea. Because, according to my observa¬ 
tions, a good doctor is a man who understands human nature and 
who understands his patients and who for that reason becomes an 
effective practitioner. That, I should think, is particularly true in 
the case of psychiatrists who, after all, need to understand people if 
they want to get anywhere with them. 

That was the first step in my logical development. The next step 
was that you as psychiatrists are naturally interested in security, 
personal security, giving a person a feeling of security, of stability. 
At the same time you are interested in professional freedom. I being 
interested in political philosophy, am interested in the same reconcili¬ 
ation—that is, group security—by means of economic planning and 
the instrumentalities of government, and also the preservation of 
individual freedom. Hence it occurred to me that this reconciliation 
of security and freedom is, in all probability, the most important 
problem that is going to confront us in the period after the war, and 
one reason I feel safe in making that assumption is because ever since 
people began to write political philosophy, this has been one of the 
recurring problems: How can you have that degree of security 
which affords the necessities of life to all people and at the same time 
provides gifted individuals or particularly skilled individuals with 
that degree of freedom, independence and integrity to make it pos¬ 
sible for them to put forth their best efforts? Everybody is asking 
this question these days. 

Everyone is saying, “How can I be a public citizen and at the same 
time an individualistic citizen?” Now, this takes different forms from 
the standpoint of vocabulary because, after all, these professional dif¬ 
ferences are primarily differences of vocabulary, but the meanings 
are common to all. And so what I am looking for as a basis for 



CONCLUSION 


157 


establishing a relationship between us this evening is an attempt to 
find what is common between us by emphasizing significances or 
interpretations, and at the same time I am asking you to overlook 
my layman’s vocabulary. 

The impact of the war has made it inevitable that everybody 
should be asking this question: “How can I reconcile the demands 
of security with my individual desire for freedom such as we have 
known in the past?” And judging from what I hear at the meetings 
of the War Manpower Commission and read in the press, none has 
responded more completely than the medical profession. In com¬ 
parison, discussions of group medicine, which in the last few years 
have been agitating your profession, shrink into relative insignifi¬ 
cance. Every once in a while, however, physicians whom I know 
have some spare time and they ask themselves in a moment of re¬ 
flection, “I wonder if I will be as free as I used to be; have my integ¬ 
rity and independence respected; have my patients choose me, or 
be assigned by someone else.’’ 

As I said, almost everybody in America today is asking this ques¬ 
tion in one form or another and American seaman are no exception. 
As has been said here several times today, the American seaman 
typically is fiercely individualistic. He wants his private life re¬ 
spected; does not like supervision or solicitousness, especially when 
he is ashore; demands respect for his freedom and individuality be¬ 
cause he is equally determined to assure these same rights to every¬ 
one else. He wants security against disease, dependency, and other 
social hazards, but he wants them as a right, not as a charity. He 
wants them as a buttress to his freedom, not as a load upon it. 

The government he looks upon in much the same way as do 
doctors and the rest of us—respects it as long as it respects him. He 
calls upon it for many rights and services, but insists that it keep 
within its appropriate sphere and not tread upon his or his group’s 
toes. Eighty-five per cent of all American seamen belong to labor 
unions. So far as I can discover, seamen have the-same concerns 
about the government’s trespassing in this precinct that doctors have 
in their solicitude for medical practice. 

All of us live by our expectancies. In our complex society all 
government and group behavior rest upon and induce understand¬ 
ings, reactions, and conditions that operate with enough regularity 
to make possible some forecasting of behaviors and counterbehavior— 
to permit the establishment of reasonable expectancies as to what will 
happen if A does this or B does that.’’ Here we find the physical 


V 


158 


TRAUMATIC WAR NEUROSES 


and social sciences drawing together, controlled by the same human 
characteristics which give rise to the basic problem of both. 

Ultimately economics and statecraft resolve into a question of 
incentives: what makes men work, love, compete, and die? Govern¬ 
ment is based upon and essentially limited by the “way of life” of 
any group of people. Does not the same consideration apply in the 
prevention and treatment of disease, especially those of a nervous 
variety? As the editors of fortune have recently said, in attempting 
to chart the new world, “We now know that the science of economics, 
like old J. P. Morgan’s lawyer, exists not to tell us what we may do, 
but how and at what cost we can best do what we want to do. And 
what we want to do—our social aims, our national purpose—are not 
in the last analysis economic decisions. Such decisions must draw 
from deeper soil: from politics, from ethics, from religion, from the 
spirit of a living society.” 

If we were able to lay bare the truths of individual psychology, 
would we then be able to predict reliably the behavior of men in 
groups? I, for one, do not think we could, for group situations in¬ 
troduce a series of variables which affect and control such behavior. 
Such things, for example, as I, as a student of institutions, have been 
interested in studying what we call in my field institutional resis¬ 
tances. 

However, it seems safe to say that certain factors are common 
to both your profession and mine. One of these is security; security 
of food, raiment, lodging, means of livelihood. Another is self- 
expression, and others are status, recognition, reward, incentive. 

The reconciliation of security and incentive, the admixture 
of basic needs and room for expansion is society’s oldest problem, 
the yardstick of many professions, including psychiatry and statecraft! 

Except for purposes of classification and analysis, the distinction 
between individual and social psychology is practically non-existent. 
The individual who never associates with another is rare; individ¬ 
uality is a social product. 

Ours has rapidly become a society in which organization and 
management are the keystones. The number of self employers 
shrinks with every generation; large corporate structures employ 
most of our manpower; labor bands together in aggregations, at¬ 
tempting to have equal bargaining power; farmers form national 
associations and wield unexcelled political power, 


CONCLUSION 


159 


In this vast welter of organization and management, democracy 
must find a balancing of interests which will add up to public in¬ 
terest; balance one group against another so that none will have too 
little and none too much. 

Professor Burnham has called this “The Managerial Revolution.” 

I hope time proves him wrong and that it is merely a management 
age rather than a revolution, for revolution would mean the end 
of democratic controls over those who represent us. Of this we may 
be sure, though, that all interests tend to grow in size and concen¬ 
tration; that those who manage these aggregations increase corres¬ 
pondingly in power and influence; that large size tends toward 
standardization and the swallowing up of countless individuals’ op¬ 
portunities for self- expression; and that the maintenance of a 
statesmanlike balance taxes the ingenuity and practical ability of 
all who wield power. The first step in solving the problem is to 
secure an awareness of what the problem is and what the non-fi- 
nancial incentives are that must be saved. In this I assume that social 
and psychiatric prescriptions find another point in common. 

If a man is to respond to the survival requirements of his new 
environment, he must understand the workings of large organization. 
That the medical profession is aware of this responsibility, I know 
from personal knowledge; for example, as long as ten years ago future 
hospital administrators were enrolled in my course in public admin¬ 
istration at the University of Chicago by one of your associations, 
the assumption being that hospital administration is only a special 
aspect of the principles of large-scale management. A member of 
my family has just returned from the Mayo Clinic and reports that 
it is as smoothly and efficiently run as the best of our large corpora¬ 
tions, blending a judicious mixture of individual consultation with 
clinical reports by specialists. 

If security and professional freedom are to be reconciled, it must 
be effected within the framework of skillful administration. To 
some suggestions on this subject I now devote the balance of my time. 

The administration of the five rest homes whose work made this 
conference possible may be taken as an example of democratic admin¬ 
istration. I use them for illustrative purposes, realizing full well 
that after such a short period of operation we cannot reliably assess 
their degree of success. 

The War Shipping Administration is responsible for financing 


160 


TRAUMATIC WAR NEUROSES 


them*. Then we have entered into a contract with a private welfare 
organization, the United Seamen’s Service, to do certain things 
which can probably be done better by it than by the government 
itself. Recreation and welfare services will be furnished by the 
United Seamen’s Service, and that agency will also process the ac¬ 
counts of these projects. A line has been drawn between the business 
or managerial end of the operation and the medical side of the pro¬ 
gram. Both are responsible to a single official of the War Shipping 
Administration and work in close association, so that in reality there 
is a differentiation of professional function but a single responsibility 
for results. 

The United States Public Health Service assists the War Ship¬ 
ping Administration in' many ways, by attaching and assigning 
personnel, consultation, conferences of this kind—everything that 
has to do with the medical side, and yet throughout it respects the 
single line of administration and operation. Then in each area 
where a convalescent home is located, doctors like yourselves offer 
their services on a part-time basis, providing the best medical staff 
procurable and treating the individual cases. The labor unions are 
’ active in the program, for this is their first priority in terms of essen¬ 
tial welfare programs, and hence they refer their members, check 
up on the homes, see that they are regarded as rest homes rather 
than “nut houses.’’ 

All of which is part of the process of keeping management demo¬ 
cratic, counterbalancing the lopsidedness of experts in any field. 

The steamship operators also come in at this point, though not 
so prominently. Finally, there are a host of other interested agencies 
which sometimes refer patients—the Red Cross, Travelers’ Aid, and 
seamen’s welfare societies. The aggregate is large but the special¬ 
ized contribution of each is necessary to the total result. 

Perhaps the most important points which emerge are that the 
medical men’s professional competence is respected and considered 
the center of reckoning; a direct line of administrative operations is 
kept intact; and the interest and participation of the seamen them¬ 
selves is actively solicited. 

Management should be thought of as all the plans, materials and 
interests which are necessary to accomplish a particular design. It 





CONCLUSION 


161 


/ 


IS not merely the raw bones of organization. It is more than the 
techniques of the trade. It is a blend of social purpose, the people 
to carry it out, and the organization through which it works. I em¬ 
phasize this point because there is a tendency to get away from it and 
separate means and ends. This must never be allowed to happen. 
Only by keeping them together is there any hope of reconciling secur¬ 
ity and freedom, liberty and equality, specialization and opportunity 
for individual development. If you are one of those rare persons 
who finds time to read outside of your field, I suggest the last chapter 
on the objectives of management in a book entitled, “The Frontiers 
of Public Administration,” by Gaus, White, and myself, written in 
a language which is not technical. 

Management must be kept democratic as well as made efficient if 
there is to be any hope of reconciling public need and private expect¬ 
ancy. People work much harder for programs that they feel they 
have had a part in shaping. You men who deal constantly with the 
clogging and release of motive powers would find worth while read¬ 
ing, I believe, in Gaus’ essays in the “Frontiers Book,” Ordway Tead’s 
“Art of Leadership,” or Merriam’s “What Is Democracy?” because I 
can sincerely say that I believe these books, these particular books that 
I am mentioning, are of as much interest to psychiatrists as to people 
who are called political scientists or public administrators. 

Another characteristic of democratic administration is that it 
gives interest groups their appropriate role to fill. This has a ten¬ 
dency to complicate organization as well as policy decision, but that 
is the price we must expect to pay for the rule of the many. And it 
is cheaper and better in the long run. It is based upon psychologi¬ 
cal needs and expectations; it guards against imbalance; it keeps 
experts from going overboard; it prevents lots of mistakes. I am 
not trying to give you a short course, but I suggest that you might be 
interested in Public Administration and the Public Interest, by E. 
Pendleton Herring. This book, incidentally, is written by the son 
of a Hopkins doctor whom I knew in the days when I was attending 
Johns Hopkins. 

There are ways of safeguarding against the confusion caused 
by interest representation and conflicting democratic counsel. A 
straight line of administrative organizations and authority can be 
provided, and usually should be, and if it were done more frequently. 


162 


TRAUMATIC WAR NEUROSES 


we would be getting on with our war effort even better. This 
straight line of administrative functioning is described in a book by 
Mooney and Reilly, entitled “Principles of Organization.” 

Part of this process is to give everyone a clear idea of his job; not 
so much what he should do, but how his little role fits into the larger 
purpose; sell a man on the importance of what he is doing and or¬ 
dinarily he will do it better. Orient him. That is not only a truth 
in management but it is a truth in human nature, which I should 
think enters also in psychiatry. 

People get mixed up in large organizations as well as in their 
private lives. It is important, too, to bring about face-to-face rela¬ 
tionships, whenever possible, instead of relying upon impersonal 
communications. This method alone puts across points of view and 
lays the foundation for mutual understanding. As Ordway Tead 
has remarked, some executives have power over people, others with 
them. 

Basically the problems of large-scale management are psycholo¬ 
gical-much more so than structural. In reality, however, as you 
gentlemen know, they do not separate, because they need to be con¬ 
sidered in conjunction. 

What will become of our society if units of organization become 
larger and larger, specialization grows apace, and the scope for most 
men’s egos grows more confined? Too much specialization, it is 
already found, disqualifies men for top executive jobs. As Dr. Par- 
ran said, let’s raise our sights and look ahead. Leaders of business, 
government, and the professions must see broadly to keep pace with 
the times, must have a human appeal to lead their followers. Special¬ 
ization narrows. Seniority ossifies. The result is that some corpora¬ 
tions I know of go out to small companies for their generalists, 
because there they have acquired breadth and still have youth. The 
resulting psychological problems challenge as much as they shock us, 
because one of the real problems of the future is the problem of 
the B man, the B man who has been passed over for the A man, the 
A man having been recruited outside of the large hierachical organi¬ 
zation while the B man is stopped at a certain point because he has 
narrowed so much that he can’t possibly go to the top. 

Can group security and professional freedom be reconciled in 
the world of tomorrow, a world of large and complex administrative 
units? It can be done, but it will require a lot of awareness, skill, 
and cooperation if it is to be done at all successfully. First, men’s 
basic needs must be assured; until this is done retrogression is inevit- 


CONCLUSION 


163 


able and people cannot well build as high as they might be able to 
above the superstructure of the basic level. Our plans should be 
decided upon after conference, representation of all parties, and 
with provision for universal participation. Fields of competence 
within the general framework should be laid out for the various 
professional and skill groups. Within these areas there should be 
self-government. Professional expectations should be assiduously safe¬ 
guarded. Any man who stands out above others in any field is a man 
who has temperament. The extra five per cent that makes man above 
average because of originality and force is something which society 
had better not meddle with if it places a proper evaluation upon it. 
We in public administration have decided that the qualities which 
produce great executives are in the area of temperament and are at 
present, at least, not measurable. Genius in any field, such as medi¬ 
cine, I suspect, is the same kind of outcropping. 

Freedom within a framework of order! Individuality within 
planned areas! I grant you that these reassuring catch phrases can 
be delusion and a snare. But nothing is impossible, if it has to be 
done, if there is sufficient awareness of the elements involved, and if 
we can produce the necessary spirit and skills to make a balanced 
system work. 

Toastmaster Parran: Ladies and Gentlemen: There was a 
famous Negro evangelist, renowned far and wide for his success in 
holding his congregation. When he was asked the secret of it, he 
said, “Well you see it’s like this. I takes my text and then I tells 
the congregation what I’se gwine to tell them, and then I tells it to 
them, and then I tells them what I has told them.” (Laughter) 

It seems to me today that we have followed that formula. 

In bringing this session to a close, I can only repeat my very deep 
appreciation to each of you for your presence and for your contri¬ 
bution to its success and thank the Josiah Macy Foundation for its 
very generous part in it, and thank with deep appreciation the of¬ 
ficials of the New York Academy of Medicine who have given us 
this very comfortable and pleasant meeting place. 

Then I would not do justice if in closing I were not to tell you 
that the inspiration for this conference came from a rather new col¬ 
league. To him I should like to express finally the appreciation 
which I think all of you feel—Dr. Daniel Blain. 

The meeting is adjourned. 

(Adjournment at 9:35 p.m.. Eastern War Time.) 




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